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
Date
Cardholders First, Last Name*

First NameLast Name
Credit Card Type*

VisaMastercardAmerican ExpressDiscover
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*

Clear
Should be Empty: