formisoft

Orthodontic Billing Authorization Form

Asks about responsible party name, treatment type, and total treatment cost. Built for orthodontic specialty practices.

Questions
10
Page
1
Time
about 3 min

Includes

  • E-signature
Use this templatePrint it instead

Your practice

Orthodontic Billing Authorization Form

Live preview. Tap through it like a patient.

Who it is for

  • Orthodontic specialty practices
  • General dentistry offices offering orthodontics
  • Pediatric dental practices with orthodontic services
  • Clear aligner provider offices
  • Multi-location orthodontic groups

Formisoft for DentalFormisoft for Pediatrics

What's inside

Before you publish: Review amounts, payment terms, and authorization wording for your practice before sharing.

  1. Responsible Party NameText
  2. Patient NameText · Required
  3. Treatment TypeLong Text
  4. Total Treatment CostNumber
  5. Insurance Coverage AvailableLong Text
  6. Insurance CarrierText
  7. Orthodontic Lifetime MaximumNumber
  8. Down Payment AmountNumber
  9. Monthly Payment AmountNumber
  10. Payment Authorization SignatureE-Signature

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Orthodontic Billing Authorization Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

Related templates

All templates

Questions

Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.

Yes. You can add, remove, reorder, or reword any of the 10 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Patients open a secure link from an email, a text, or a QR code and complete the form on their phone, tablet, or computer before their appointment. No app download required.

Yes, on Front Desk. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Yes. The Orthodontic Billing Authorization Form works on any device. Most patients complete intake forms on their phone, so every template is built for small screens first.

Send it before the visit, so patients arrive ready.

Add the Orthodontic Billing Authorization Form to your account and make it yours in a few minutes.

Cancel anytime · BAA included

Use this templateBook a demo