Credit Card Authorization Form

Credit Card Authorization Form
I authorize BERKELEY/ORINDA ORTHODONTICS to charge my credit card account according to the payment schedule and amount outlined in the treatment contract.
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cardholders First, Last Name

First NameLast Name
Credit Card Type
Credit Card Number
Expiration Date
2 Digit Month and Year - example 03/20
Security Code
CVC code
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Signature Required
Should be Empty: