Auto-Pay Authorization Patient Name* First Last Date* Date Format: MM slash DD slash YYYY Bank ACH routing #*Bank Account #*Please choose type:*PersonalBusinessChecking/Savings?*CheckingSavingsDate of the month to withdraw funds*5th12th19th26th I authorize Schmidl Orthodontics to make monthly withdrawals from my account in the agreed to amount on my financial contract.Responsible Party*Responsible Party Signature*
