Prescheduled Payment Request

Spectrum Dental Laboratories accepts checks and credit cards. For your convenience, credit card payments can be prescheduled for any day of the month. When your card is on a prescheduled payment plan, we will charge the account balance to that card every month on the day of your choosing for the amount that appears on last month statement.
If you are interested in prescheduled payment, please feel out this form below, or you can download and mail or fax the form.
If you have any additional questions, please feel free to call Olga at (714) 426-2900.
Thank you for choosing Spectrum Dental Laboratories.

Prescheduled Payment Day of Month: *

Beginning (5th) Middle (15th) End (29th)

Name on Credit Card: *

First

Last

Card Type: *

Visa Mastercard Discover American Express

Credit Card Number: *

Expiration Month: *

CVV/CID Code: *

Expiration Year: *

Billing Address: *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number: *

Fax Number: *

Email: *

Comments: *

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