Square Statement Payment

Patient Name *

First Name Middle Name Last Name

Statement Amount to be charged *

USD Statement Amount

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Statement Date *

Month Day Year

Was statement paid in full? *

Yes, Statement was paid in full. No, Statement was not paid in full. Please set up monthly payments until balance is fully paid. No, Statement was not paid in full. Do not set up monthly payments.

Recurring Payment Credit Card Authorization Form
Schedule your payment to be automatically charged to your Credit Card.

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be sent to you. You agree that no prior-notification will be provided unless the date or amount changes.

You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Cardholder Name *

Card Type *

Card Number *

Expiration Date *

Cardholder zip code *

Amount to charge monthly *

Day of the month to be charged on *

Total bill $ *

*

Signature *

Clear

E-mail

Contact Number:

Area Code Phone Number

Optional questions for biller:

Pay Statement