Screen 7 of 14

Authorise this payment plan

This is what Maria Alvarez sees on her own phone. She reads what she is agreeing to, ticks it, signs it, and the receipt lands before she puts the phone down.

Nothing on this page is real. No card is read, no money moves, and no message is sent.

What you are agreeing to

The payment plan being authorised
Paying	Horizon City Orthodontics
For	Sofia Alvarez
Each payment	$200.00
Taken on	The 5th of each month
First payment	October 5, 2026
Payments left	16
Card on file	•••• 8891
Cancel or change	(915) 555-0142

No card was entered anywhere in this walkthrough. The digits above are a placeholder, and the plan is the same mock plan used on every screen here. MODELLED

The fee, before you pay

Families pay a $5.95 technology fee on each payment, shown before the payment is made. The practice never sees it and never handles it.

That figure is the price set for this mock walkthrough, not a measured number. MODELLED

It is on this screen because a fee a payer meets for the first time on a bank statement is a fee nobody agreed to.

Your permissions

I authorise Horizon City Orthodontics to charge this card for the amounts and on the dates shown above, until this plan is paid. Required. You can cancel at any time by calling the practice. After you sign, you can print or save your own copy, with these amounts and these dates, from the receipt on the next screen. See the payment plan terms, further down this page. Text me about this payment plan: receipts, a reminder before each payment, and a message if one does not go through. Optional. Message and data rates may apply. Reply STOP at any time.

Two things are asked here and nothing else: the charges, and whether the practice may text you about them. Marketing is not one of them.

Sign the authorisation

Your name is already filled in from the practice record, so the only thing left is your signature.

Sign here draw your signature with a finger, a stylus or the mouse, or press the button named Sign with my typed name

Signing as filled in from the practice record

Signature of the responsible party

Draw your signature above

The signature is drawn on the page and kept with the authorisation. A copy goes to you, and a copy stays with the practice.

Does everything look correct?

A last look before authorising
Paying	Horizon City Orthodontics
Charged on the 5th	$200.00
Card on file	•••• 8891
For	Sofia Alvarez
Signed by	Maria Alvarez
Date

These are the same figures as the plan at the top of this page. MODELLED

Payment authorised

The plan is signed. The first payment is scheduled for October 5, 2026. Nothing further is needed from you.

Receipt

This is the receipt for the first payment, taken on October 5, 2026. It is shown now so you can see both lines before either one reaches your statement.

There are two lines, because there are two merchants.

Statement line one, Horizon City Orthodontics

$200.00, the instalment on your plan.

Paid to the practice.

Statement line two, NextRev

$5.95, the technology fee.

Paid to NextRev. The practice never sees it and never handles it.

These are two separate lines on your statement, and they are never merged into one.

Receipt details
Card charged	•••• 8891
Authorisation code	418702
Reference	NR-ALV-7QK4M2
Patient	Sofia Alvarez
Posted to the practice ledger	posted

The two amounts are the mock plan's figures, and the code and the reference are invented for the walkthrough. MODELLED No payment was taken and no ledger was written.

What you agreed to

Charge this card $200.00 on the 5th of each month, until this plan is paid.
Texts about this payment plan.
Signed by Maria Alvarez.
Nothing else. Marketing was not part of this, and it is asked separately below.

Sent

Where the receipt went
Receipt emailed to	m.alvarez@example.com
Receipt texted to	(915) 555-0166
Copy kept by the practice	on file

Nothing was actually sent. This is a mock: it has no mail account, no messaging account and no server, and a static page that could send one text could be made to send a thousand.

What happens from here, with nobody chasing you

Before each payment, a reminder goes to the responsible party.
On the day, the stored card is charged and the receipt goes out.
If a payment does not go through, the office is told the same day, and so is the payer.
Every posting lands in the practice’s own ledger, so the office reconciles in the software it already uses.

Nobody at the front desk chases any of this. That is the point of it.

Posting the payments into the practice ledger stays a person’s click in Ortho2, the same as it is today. The software does the typing, not the deciding.

One more thing, and it is entirely optional

Email me news and offers from NextRev. Nothing to do with the payment you just made, and it changes nothing about your plan. Unsubscribe at any time.

Read the payment plan terms

Payment plan terms

Payment plan terms
Who you are paying	Horizon City Orthodontics
What is charged	The amounts and the dates shown on your plan, and nothing else
How to cancel	Call (915) 555-0142 at any time
If an amount changes	You are told before the next payment is taken
Where your card is held	With the payment processor, not with the practice
Your copy	Kept on file and available to you on request

Card details are captured by TRX Services on their own systems. Neither the practice nor NextRev receives or stores your card number. A stored card is used only for the payments on this plan.

Sample terms, for a walkthrough. A live practice carries its own agreement, reviewed by its own counsel.