Authorization for Autopayment
Client Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Payment Authorization
*
I, the undersigned, authorize Nulton Diagnostic & Treatment Center, its billing service, or designated respresentatives to initiate a recurring debit entry from the amount specified below, for payment of services rendered.
Amount to Charge
*
Acount Balance
Other
If "Other" please indicate the amount to be charged:
Date of Monthly Charge
*
Please Select
20th day of each month
1st day of each month
Billing Information
Credit/Debit Card Information
Cardholder Name:
*
Card Number:
*
Expiration Date (MM/YY):
*
Authorization Terms
*
I understand that: This authorization will remain in effect until I cancel it at least 7 days' notice before the scheduled payment date. If the scheduled payment date falls on a weekend or holiday, the charge may occur on the next business day. A $35 fee may apply for any returned or declined transactions. I am responsible for ensuring sufficient funds are available on the scheduled date.
Signature
*
Continue
Continue
Should be Empty: