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 Name Last Name
Date *

Month Day Year
Date
Cardholders First, Last Name *

First Name Last Name
Credit Card Type *

Visa Mastercard American Express Discover
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

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Signature Required *

Clear
Should be Empty: