Customer Name:*

Customer Number:*

Billing Item*

Ads
Hosting Fee
Mktg Non Dental
Mktg Reputation Mgmt
Mktg SM-Budget Upgrade-FB Ads
ORCA - Access Only
ORCA - Combined Mgmt Fee
ORCA - DeNovo
ORCA - Digital - Bing Mgmt
ORCA - Digital Mgmt Fee
ORCA - Facebook Ads Mgmt
ORCA - Mail
ORCA - Mail Ala Carte
One-time Charge
PPC a la carte
SEO Only

Adjustment Type*

One Time Charge Amount

Charge Description*

NOTE You've selected "Cancellation Form" this form will NOT be sent to the billing department

Increased TO*

Billing will be increased TO this amount

Product*

Decrease To*

This is the new amount the client will be billed

Reason For Decrease*

Refund Amount*

Credit Memo Amount*

Duration (Is this Recurring, one-time or does it have an end date?)

Reason For Cancellation*

Do they have mail?*

Yes
No

Do they owe money?*

Yes
No

Best Contact Number*

Best Contact Email*

Services Provided*

Billing Amount*

Reason For Pausing Billing*

Last Day of Service*

Removed Service*

New Service Set Up Fee?*

Yes
No

New Service Set Up Fee*

Monthly Billing Amount For New Service*

Written Cancellation Date*

Amount To Bill Customer*

This will be the amount on the invoice that billing sends to the customer.

Reoccurring Charge*

Yes
No

Attachments

Drop files here or

Notes*

(Any other details? Ex. BA Legacy Client)

Is There A Commission?*

Yes
No

Approved By*

Submitted By*

First Last

Your Email Address*

*NOTE* You've selected "Cancellation Form" this form will NOT be sent to the billing department

NOTE You've selected "Cancellation Form" this form will NOT be sent to the billing department