---
title: Orthodontic Treatment Payment Plan Application Form Template | Paperform
description: Professional payment plan application for orthodontic treatment with insurance coordination, family discounts, and automatic payment setup. Perfect for dental practices.
url: "https://paperform.co/templates/orthodontic-treatment-payment-plan-application"
type: static
generatedAt: "2026-03-28T00:44:41.918Z"
---

[← Back to free form templates](/templates/)    ![Orthodontic Treatment Payment Plan Application](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/orthodontic-treatment-payment-plan-application.png)
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### Simplify Orthodontic Payment Plans with Paperform

Managing orthodontic treatment financing shouldn't add complexity to your practice. Whether you're a dental clinic, orthodontist office, or healthcare provider offering specialized treatments, this **Orthodontic Treatment Payment Plan Application** template helps you streamline payment approvals, coordinate insurance benefits, and set up automatic payment schedules—all in one professional, patient-friendly form.

#### Why Digital Payment Plan Applications Matter

Orthodontic treatment is a significant investment for families, often spanning 18-24 months or longer. Traditional paper applications create administrative bottlenecks, delay treatment starts, and increase the risk of errors in insurance coordination or payment calculations. By digitizing your payment plan process with Paperform, you can:

 - **Approve patients faster** with instant submission notifications and automated workflows
 - **Reduce billing errors** through built-in calculators for treatment costs, insurance offsets, and family discounts
 - **Improve patient experience** with transparent pricing and flexible payment options
 - **Automate follow-ups** for missing information or required signatures

#### Built for Orthodontic and Dental Practices

This template is specifically designed for orthodontists, pediatric dentists, and dental practices offering payment plans for braces, Invisalign, retainers, and other orthodontic treatments. It captures everything you need to assess financial eligibility and set up a payment arrangement:

 - **Patient and guarantor information** with emergency contacts
 - **Treatment details** including procedure type, estimated duration, and total cost
 - **Insurance benefit verification** to calculate out-of-pocket costs
 - **Family discount calculator** for multiple family members in treatment
 - **Payment plan preferences** with down payment and monthly installment options
 - **Automatic payment authorization** for credit cards or bank accounts

The form uses conditional logic to show relevant questions based on insurance coverage and payment preferences, keeping the experience streamlined for patients while ensuring your practice collects all necessary information.

#### Smart Calculations That Show Patients Exactly What They'll Pay

One of the biggest anxieties patients face is uncertainty about final costs. This template includes **dynamic pricing calculations** that update in real-time as patients enter their information:

 - Subtract insurance benefits from total treatment cost
 - Apply family discounts automatically when multiple members are in treatment
 - Calculate monthly payment amounts based on chosen plan duration
 - Show clear breakdowns of down payments, monthly installments, and total financing costs

Transparent, upfront pricing builds trust and helps families make confident decisions about starting treatment.

#### Seamless Integration with Your Practice Management Tools

Paperform connects with the tools dental practices already use every day. Send approved applications directly to your practice management software (Dentrix, Eaglesoft, Open Dental), log patient information in your CRM, create tasks in Asana or Monday.com for your billing team, or trigger automated email sequences for payment reminders.

For practices using **Stepper** (stepper.io), you can build multi-step workflows that automatically route applications for credit approval, send contracts via **Papersign** (papersign.com) for eSignature, and schedule the first appointment—all triggered by form submission. This means less manual data entry and faster time-to-treatment for your patients.

#### Secure, Compliant Financial Data Collection

Healthcare financial information requires the highest level of security and professionalism. This template is built on Paperform's **SOC 2 Type II compliant platform**, ensuring patient financial data is encrypted and handled according to industry best practices. You can customize success messages, set up HIPAA-compliant integrations where needed, and control exactly who on your team has access to sensitive payment information through role-based permissions.

#### Perfect for These Healthcare Professionals

 - **Orthodontists** offering flexible financing for braces and clear aligners
 - **Pediatric dentists** providing payment plans for comprehensive treatment
 - **Dental practice managers** streamlining billing and payment operations
 - **Cosmetic dentists** offering financing for smile makeovers and veneers
 - **Oral surgeons** providing payment options for surgical procedures

#### Why Paperform for Healthcare Payment Plans?

Unlike generic form builders, Paperform gives dental practices the power to create forms that look and feel like part of your brand—not a clunky third-party tool. The doc-style editor makes it easy to add your logo, match your website colors, and write in your practice's friendly, reassuring voice.

With built-in **payment processing through Stripe and Square**, you can even collect down payments directly in the form, reducing friction and no-shows. Conditional logic ensures patients only see relevant questions, and calculation fields do the math automatically so families see exactly what they owe before clicking submit.

For practices managing multiple locations or brands, **Agency+ features** let you duplicate and customize this template for each office while managing everything from one central dashboard.

Start using this Orthodontic Treatment Payment Plan Application template today and transform how your practice handles treatment financing—giving families confidence and your team more time to focus on patient care.
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