iPosPays Payment Form

Amount: $0.00

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Description :

Card Number *

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Card Holder Name

Additional Details

Customer Name *

Routing Number*

Account Number*

Account Name*

Routing Number*

Account Number*

First Name

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Address 1

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Custom1

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Custom3

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Terms and Conditions

By clicking “Process” below you are authorizing this ACH transaction
By authorizing this transaction customer agrees that company named above may convert this transaction into an Electronic Funds Transfer (EFT) transaction to send via ACH debit to the bank account for the amount indicated above.
To revoke this authorization contact Customer Support at +16466877898 or info@madisondentalloft.com within 48 hours prior to the Payment Effective Date.
Processing times may not allow for revocation of this authorization.
Additionally, in the event this ACH is returned unpaid, a service fee in the amount of $25.00 (or maximum allowable by law) will be charged to the bank account indicated via ACH.

MADISON DENTAL LOFT PC

30 E 40th St Rm 806

Amount: $0.00

SALE:

$ 0.00

$0.00

TIP:

$0.00

$0.00

$0.00

Food Amount:

$0.00

$0.00

Description :

Processing your request

Processing your request

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