Enter OTP
Time remaining: 06:00
Donation
i
Would you like to round up your amount to the next dollar to donate to the Charity?

Affordable Smiles of Houma
1861 Martin Luther King B, Houma
Louisiana, 70360.

$

*Please fill amount field

0000 0000 0000 0000 cardholder name expiration card number 01/23 VALID THRU
985 CVV/CID John Doe

I agree to the Terms And Conditions

i
To complete the payment, please generate an OTP.

Acknowledgment

The customer hereby authorizes Affordable Smiles of Houma to debit their bank account for all funds due to Affordable Smiles of Houma, without regard to the source of such funds in the account. With respect to Automated Clearing House (ACH) settlement of transactions (i.e., electronic debits and credits to and from the customer's bank account), the customer hereby agrees to be bound by the terms of the operating rules of the National Automated Clearing House Association and authorizes Affordable Smiles of Houma to initiate ACH debit or credit entries and adjustments to the bank account for all products and/or services provided.

Affordable Smiles of Houma shall not be liable for any delays in receipt, debit, or disbursement of funds, or errors in account entries caused by third parties including, but not limited to, the Association or the bank. The customer shall not close the account without providing Affordable Smiles of Houma with written notice of such closure and substitution of another account at least five (5) days prior. The customer shall be solely liable for all fees and costs associated with the account.

If Affordable Smiles of Houma initiates ACH transactions to the customer's bank accounts, all parties agree to be bound by all terms of the most recently signed ACH agreement. In all cases, the customer shall ultimately be responsible for all funds due.

I agree to the Terms And Conditions

Powered By https://online.valorpaytech.com/assets/Valor_Logo_1-0e4fc39f.svg

Verified By https://swipe4free.com/wp-content/uploads/2020/06/security-icon.png