• Credit Card Authorization

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  • 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 * hereby agree to the above agreement.

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