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Elevate Dental Credit Card Vault Authorization
-We adhere to the highest standards for account data protection and encryption-
Please choose:
and to charge my:
Choose authorization option
If authorizing copayments after insurance, indicate amount 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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