Refund Request

Please complete the form below to request a refund from Dino Kids Dental. We will review your request and reach out if we need anything else.

Important Note (Read Before Submitting)

We only process refunds via Zelle® or ACH (bank transfer).

A $25 account audit fee may apply.

Please allow 4 to 6 weeks to process your request.

What You’ll Need

If selecting ACH, you may either enter your bank details or upload documentation:

Voided check or bank letter

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This field is for validation purposes and should be left unchanged.

Refund amount requested(Required)

Patient name(Required)

Patient ID(Required)

Phone number(Required)

Email address(Required)

Office location visited(Required)

Date of Birth(Required)

Other Location

Mailing Address(Required)

Reason for refund request(Required)

Refund Delivery Method

How would you like to receive your refund?(Required)

Zelle®

ACH (Bank Transfer)

Zelle® recipient name(Required)

Zelle® phone number(Required)

Zelle® email(Required)

ACH option(Required)

Enter bank account information

Upload voided check

Upload bank letter

Account holder name(Required)

Bank name(Required)

Routing number(Required)

Account number(Required)

Verify Account number(Required)

Account type(Required)

Upload voided check(Required)

Accepted file types: pdf, jpg, png, Max. file size: 32 MB.

Upload bank letter(Required)

Accepted file types: pdf, jpg, png, Max. file size: 32 MB.

Optional (Recommended) Fields

Last 4 digits of card used

Preferred callback time

Required Acknowledgment / Consent

Untitled(Required)

I understand refunds are processed via Zelle®/ACH only + $25 audit fee may apply + 4–6 weeks.

I understand that as an insured patient, my insurance company can audit records within the statute of limitations of each state. If at any time within the permitted statute of limitations my insurance determines that there was a mistake on any payment made towards claims submitted on my behalf I will be responsible for any amount recouped by my insurance company.

I understand that I will have up to 30 days to make payments or arrangements to cover any amount recouped. I understand that failure to do so may result in Collection Efforts and reporting.