Make a Payment — Smith Orthodontics

Securely pay your balance below. Once your payment is processed, you'll be able to download a receipt for your records.

Please correct the following:

Patient Information

So we can apply this payment to the correct account.

Patient First Name *

Required

Patient Last Name *

Required

Patient Date of Birth *

Required

Parent / Guardian Name — if applicable

Email *

Valid email required

Phone — optional

Payment Details

Enter the amount you'd like to pay today.

Amount *

Enter an amount of $1.00 or more

Note — optional

Payment Method

Your card details are encrypted and processed securely by Stripe.

Card Information *

Secure payment powered by Stripe · Smith Orthodontics never stores your card details

✓

Payment Received

Thank you! Your payment has been processed successfully. A confirmation has been sent to our team. Please save or print your receipt below for your records.

Receipt Summary

Receipt No.—

Date—

Patient—

Payment Method—

Amount Paid—