Floral Image - Dallas Credit Card Form

My Tuition Payment

USDDescription

Credit Card

Apple Pay

Google Pay

First name
Company Name
Last name
Company Name
E-mail
example@example.com
Phone Number
Please enter a valid phone number.
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize Professional Allied Health LLC to accept the payment indicated in the authorization for the services described above. I certify that I am an authorized user of this credit/debit card and that I will not dispute the payment with my credit/debit card company and /or financial institution; so long as the transaction corresponds to the terms indicated on this form. (Please type OK and YOUR NAME in the box below)*
Authorization Signature

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Tuition Payment Form