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Elevate Dental Credit Card Vault Authorization
-We adhere to the highest standards for account data protection and encryption-
We highly recommend you allow us to save your card in the vault that way we do not have to contact you over a minmal amount that your insurance did not pay.
Please choose:
and to charge my:
Choose authorization option
If authorizing copayments after insurance, indicate amount ($) to not to exceed:
Billing Details
Cardholder FirstName
Cardholder Last Name
Credit Card Number
Exp. Date
Security Code (CVV)
Billing Zipcode
Patient First Name
Patient Last Name
Date Of Birth
Patient/Legal Guardian Signature
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Signature Pad
Date
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