Billing: billing@mandeldermatology.com

I, the undersigned cardholder, authorize Mandel Dermatology and its affiliated entities (collectively, "the Practice") to charge the payment card identified below for any and all charges incurred by the authorized user named below in connection with services, products, visits, procedures, treatments, packages, memberships, no-show or late-cancellation fees, patient-responsibility balances after insurance adjudication, and any other charges arising from the authorized user's relationship with the Practice. I acknowledge and agree that:

1. This authorization applies to card-not-present transactions and permits the Practice to keep my card on file and charge it without my physical presence or additional signature at the time of each charge.

2. This authorization is ongoing and remains in effect for all future charges incurred by the authorized user until I expressly revoke it in writing by email to billing@mandeldermatology.com and receive written acknowledgment of the revocation from the Practice. Revocation is not effective until acknowledged by the Practice in writing, and does not apply to charges already incurred or in process at the time of acknowledgment.

3. I have reviewed and agreed to the Practice's financial policy, and I accept responsibility for all charges made under this authorization, including charges the authorized user incurs without my contemporaneous knowledge.

4. I waive any right to dispute, chargeback, or otherwise contest charges made under this authorization on the grounds that the transaction was card-not-present, that I was not physically present at the time of service, or that the authorized user — rather than I — received the goods or services. I agree that any billing concern will first be raised directly with the Practice at billing@mandeldermatology.com in good faith before any dispute is initiated with my card issuer.

5. I represent that I am the lawful cardholder of the card identified below and am authorized to grant this permission.