Credit Card Authorization
EXPRESS CHECK OUT:
 
I hereby authorize The Center for Pediatric Dental Care LLC to keep my signature on file and charge my credit card account selected below for the following:
I hereby authorize The Center for Pediatric Dental Care LLC to keep my signature on file and charge my credit card account selected listed above. I understand this form is valid unless I cancel this authorization by written notice. If I choose to cancel this form, I assume full responsibility for paying my charges in full at the time of service.