Form

Credit Card Authorization Form

Due to COVID-19, our office is as touchless as possible. Because of that, we ask that all patients give us a credit card on file so that we can charge without contact. We will not charge your card until you have been in the office for treatment. If there is a remaining balance of $200.00 or less after insurance and your estimated copay has been paid, we will charge your card without additional notice. If the balance is over $200.00, we will contact you for review. We also use electronic invoicing through our software partners, Abella and NextHealth.

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.

Card Type (AMERICAN EXPRESS IS NOT ACCEPTED)

Cardholder name (as shown on card)

Card number

Expiration Date(mm/yy)

CVV (3 digits on back)

Cardholder ZIP Code (from credit card billing address)

, authorize Sheila Dobee DDS Inc. to charge my credit card above for agreed-upon treatment. I understand that my information will be saved to my file for future transactions on my account as mentioned above.

Patient/Legal Guardian Signature

Date