Pay Your Bill

Take care of your bill online!

Please complete the form below to pay your bill. If you have any questions or concerns please call us at 515-987-8387. Thank you!

All fields marked with * are required.

Patient Information

Patient Name *

Phone Number *

Email Address *

Payment Details

Account Number *

Payment Amount *

Credit Card Number *

Expiration Date *

CVV Code *

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Billing Details

First Name *

Last Name *

Address 1 *

Address 2 (optional)

City *

Select a state *

Zip *

We are here to give you the confidence and smile you've always wanted!