Payment Form — Your Smile, Our Priority, Anywhere

Payment Form.

If you encounter any difficulties while filling out the form, please reach out via email to request a PDF attachment.

This payment form is essential for children who are ineligible. Benefit from a discounted rate, reduced from $169 to just $69 for a limited time.

School/Day-Care Name

Child Name

First Name

Last Name

Child Date of Birth

Email

Parent/ Guardian Name

First Name

Last Name

I consent for my child to be seen by Dentist/Therapist

Check-up & Clean

Name on the card

First Name

Last Name

Card Number {Only numbers No spaces}

Expiry Date

MM

DD

YYYY

CCV

Phone Number

(###)

###

####

Payment will be settled following the child's dental check-up.