Request Refund Clementon

Brighter Dental Care

Request for Refund - Clementon
(* required field)

*Date

/ / (month/date/year)

*Patient Name

*Account Number

*Mailing Address 1

Mailing Address 2

*City

*State

*Zip

Type of Return (check one)

Dental Fee Plan

Before a return can be considered, you must call financing company to make sure account was funded and there have been no previous returns or adjustments.
Did you call and verify? yes no

Care Credit

Before a return can be considered, you must call financing company to make sure account was funded and there have been no previous returns or adjustments.
Did you call and verify? yes no

Unicorn Financing

Before a return can be considered, you must call financing company to make sure account was funded and there have been no previous returns or adjustments.
Did you call and verify? yes no

Citibank Financing

Before a return can be considered, you must call financing company to make sure account was funded and there have been no previous returns or adjustments.
Did you call and verify? yes no

Credit Card Refund

VISA

MasterCard

Discover

AmEx

Refund Check

** Instructions**
This form needs to be completed in its entirety and Eaglesoft account should be noted that refund request has been completed.

*Amount $

Reasons/Remarks

*Brighter Dental Employee Name