Payment / Credit Card Authorization

Please note that it is important to fill in all the fields before submitting. Thank you.

*Name:  

 *Last name

 Mid name

 *First name
*Home address:

City:
State:
Zip:
APT#:

*Email address: Social security#:

*Telephone Home: Cell phone#:
Telephone Work:

*We require a credit card number on file to process any balance remaining after your insurance company has paid. Estimated copayments are due at the time of service.

Name of credit card
Number
Expiration date   Year: Month:
Date
To be signed at the time of the appointment by the Credit Card holder