Menciagomez@1 - Credit Card Authorization

Credit Card Authorization
Patient Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name as it appears on the card
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address (where the credit card is billed to)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of CC
Credit Card Number
CVC
Exp Date
These details are for
I hereby authorize the office of Dr. Mencia Gomez to place the applicable fees for the above patient. I agree that I am responsible for these charges and agree to pay the authorizing credit card agency. In the event of a reversal of charges, I agree to pay Mencia Gomez MD, for these service plus any additional applicable fees.
I Full Name* hereby agree to the above agreement.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: