Form

Credit Card Authorization

First Name

Patient Last Name

Date Of Birth

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:

Credit Card

Items for credit card payment:

Cardholder Name

Card Number (no dashes)

Expiration

CVV

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.

Cardholder's signature

Date