Credit Card Authorization
Please complete when submitting first case.
Name of Practice
*
Name of Doctor
*
Prefix
First Name
Last Name
Suffix
Email Address for Confirmation
*
example@example.com
Customer Number (if known)
In order to keep your information secure, we will CALL your business for the credit card details. We will contact you within one full business day of submitting this information.
*
I understand this information will not be recorded on this form; it will be given over the phone. Please call the above practice for the information ASAP.
I understand this information will not be recorded on this form; it will be given over the phone. I will call Cottonwood Labs at (801) 904-2006 upon completion of this form, to relay this information.
Should we keep this card on file or is this a ONE TIME CHARGE?
*
Please keep this card securely on file for future billing purposes.
Please charge my account today and keep this card securely on file for future billing purposes.
This is a ONE TIME CHARGE, do not keep this card on file
For cards kept securely on file:
*
Automatically charge card each month
Wait for practice approval to charge card each month
NA - Dont keep this card on file
If we are charging your card today, please indicate the amount. If we are not charging your card today, please use 0.
*
Todays Amount
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
*
Submit
Submit
Should be Empty: