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Office Name

Doctor's First Name

Doctor's Last Name

Address

City

State

Zip

Phone

License

License Exp Date

Billing Contact

Clinical Contact

Preferred Method for Communication

Best Day(s)/Time(s) to Reach Office

How did you hear about us

Impression Type

True Function Laboratory, Inc. (TFL) prefers customers pay their account balance with a check. However, a valid credit card (Visa or MasterCard) is required when opening an account.

Pay by check: TFL will send an invoice with every case and mail a statement at the end of every month. The statement balance is due upon receipt (usually the 1st-3rd of the following month). The account becomes past due on the 25th of the month. If the account balance has not been paid in full by the 25th, the card on file will be charged for any unpaid invoices. If the card is declined, the office will be notified, and a prompt payment is expected. If payment isn’t received by the end of the month, a 2% finance charge will be assessed on the unpaid past-due amount.

Pay by credit card: Automatically run card at the end of the month for my statement balance. If the card is declined, the office will be notified, and a prompt payment is expected. If payment isn’t received by the end of the next month, a 2% finance charge will be assessed on the unpaid past-due amount.

Payment Choice

Card Number

Name on Card

Card Expiration

Security Code

By submitting this form, I hereby certify the information provided in this application is true, correct, and complete. I agree to be held financially responsible for any and all charges incurred at True Function Laboratory, Inc. I agree to promptly notify True Function Laboratory, Inc. of any changes in the information provided and agree to the terms noted above. I authorize True Function Laboratory, Inc. to charge my credit card per my selection in the Payment Choice area above and/or for any unpaid dental laboratory services for the previous month.

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All appliances are prescription only and are customized by True Function Lab to dentist specific instructions.

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