Request Invoices and Statements To Be Emailed

Please fill out all required sections on this form and submit

MEDENT Account Number:*

Practice Name:*

By clicking yes, you are authorizing MEDENT to send you your billing invoices and monthly statements via email rather than USPS, to the email addresses listed below.


Authorized Name:*


Email addresses to send billing invoices monthly statements to (enter up to five)

Note: We strongly recommend you use a business only email address that multiple employees have access to. Ex.( If you do not have a business email, we recommend providing multiple email addresses in the event an employee leaves the practice to ensure your practice continues to receive your billing invoices and monthly statements.

Email #1:*

Email #2:

Email #3:

Email #4:

Email #5:

Additional Instructions: