www.ashevillesmilecenter.com - Payment / Credit Card Authorization Form

Payment / Credit Card Authorization

Please note that it is important to fill in all the fields before submitting. Thank you.
Print blank form to fill by hand
Name*

First NameMiddle NameLast Name
Home Address*
Street Address, City, State, Zip, APT Number
Email Address*
example@example.com
Social Security Number
Home Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
We require a credit card number on file to process any balance remaining after your insurance company has paid. Estimated copayments are due at the time of service.
Name of credit card*
Card Number*

Street Address Line 2

CityState / Province

Postal / Zip Code
Expiration Date
Year*
Month*
To be signed at the time of the appointment by the Credit Card holder
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: