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Thanks for visiting our Patient Forms page, where you can find and access forms that will help Dr. Sturdivant better understand your needs. We thank you in advance for taking the time to fill out these forms and we look forward to meeting you soon!

For your convenience, our patient forms are available in PDF format online. Download them to the left. If you are unable to open them, you can install Adobe Acrobat Reader for free here.


I absolutely love, love, love the service, attention, and hospitality of Dr. Sturdivant and her staff. I would highly recommend her services to anyone looking for quality and professionalism. She is amazing!!!!
Nyssa Carlson Fox

Financing Options

The cost of your orthodontic treatment will vary depending on your individual needs and treatment plan. Our staff will discuss with you the cost of your treatment and each available payment plan option, so that you can make the best choice for you and your smile. We will work with you to create a payment plan that fits your budget, and you will know what to expect before beginning treatment.

In order to make your orthodontic treatment affordable, we offer:

A Discount For Payment
In Full Of The Entire Fee

A discount for payment in full of the entire fee at the start of treatment. (If you have insurance, the discount is applied to your portion of the fee only and will vary depending form of payment used.)

Payroll Tax Free Flexible Spending Accounts (FSA)

An FSA allows you to set aside a portion of your paycheck in order to pay for qualified medical expenses. The money you elect to contribute is deducted from your pay and transferred directly into your FSA and, therefore, is not subject to payroll tax. After incurring eligible medical expense, you can then submit your receipt for reimbursement from your FSA. Orthodontic treatment expense usually qualifies for FSA reimbursement. Save money and use a pre-tax contribution. Speak to your employer about this convenient way to get the smile you want.

Interest Free In-House Financing With A Down Payment

An initial down payment is due when treatment begins. For your convenience, monthly payments will be debited from your bank or account via electronic funds transfer (EFT), credit card, checking or savings account by our agent, OrthoBanc, until your entire balance is paid in full. *Failing to keep your financial agreement may result in premature treatment termination.

Convenient & Secure Online Payments

RGV Orthodontics by Dr.Gracie Sturdivant offers patients the option to pay their bills online using VISA, Mastercard, American Express & Discover. In order to pay your Orthodontics bill online you will need to enter your 6 digit account number only (no dash necessary) from your most recent statement. You can find your account number on the top right side of your statement. Please enter the amount you wish to pay. Complete the remaining mandatory fields on the following screens. Once you complete your payment you will be able to print a receipt.



Your payments will be processed thru a secure webpage hosted by TransFirst, an industry leader that processes transactions for thousands of clients. The information TransFirst receives from you will only be used to process your transactions and will never be shared with any other party, except as required by law. Your information will be safeguarded in strict compliance with federal standards for nonpublic personal information.

Simply enter your 6 digit account number and then click the “Pay Your Bill” button and follow the directions on the page.

Patient Account Number:



  • Early Bird Special
  • Sibling Discount
  • Dental Community Discount
  • New Patient Referral Program
  • Bridal and Quinceañera Smile Package
  • Service Men & Women Discounts: Armed Forces, Firefighters, Police
  • Second Phase Discount
  • Special Month Discount (Varies)
Simply leave a positive review on any Gracie Sturdivant, D.D.S. P.A social media site.(Print your completed review and bring it by our office
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