Menciagomez@1 - Credit Card Authorization

Credit Card Authorization
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Date
Name as it appears on the card*
Date*

MonthDayYear
Date
Address (where the credit card is billed to)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of CC*
Credit Card Number*
CVC*
Exp Date*
These details are for*

One time chargeRecurrent - For each Office Visit/Missed appointments/Late cancellations / Any balance incurred by patient.
I hereby authorize the office of Dr. Mencia Gomez to place the applicable fees for the above patient. I agree that I am responsible for these charges and agree to pay the authorizing credit card agency. In the event of a reversal of charges, I agree to pay Mencia Gomez MD, for these service plus any additional applicable fees.
I Full Name* hereby agree to the above agreement.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: