Credit Card Authorization Form
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1CREDIT CARD AUTHORIZATION FORM
Completed forms may be faxed (908-580-1201), emailed (), or mailed to the FEC at 140 Allen Road,
Suite 300, Basking Ridge, NJ 07920
Payment will not be processed until samples are received by the FEC. Missing or incomplete payment will delay release of
results by the FEC.
Patient Name: __________________________________________
Patient Address: ____________________________________________________________________________________________
____________________________________________________________________________________________________________
Patient Phone #: ________________________________________
Name as it appears on card: ________________________________________________
Billing Address (if different from above): _____________________________________________________________________
____________________________________________________________________________________________________________
Billing Phone # (if different from above): _____________________________________
Please send receipt to (check one or both): Patient
Cardholder
Payment Information
Accepted payment Methods:
16 Digit Card Number: ______________________________________________________
Expiration Date (MM/YYYY): _____________________________
3 Digit Security Code: ________
OR
4 Digit Amex Security Code: __________
(On the back of the card in signature box)
(Last four digits on front of card above ID)
I, _________________________________, hereby authorize FEC to charge the above credit card in the amount of
$ ____________. I understand that by signing below I am responsible for payment of the described charges in
accordance with the terms of the issuing credit card company.
Signature: _____________________________________________
Date: __________________
(Authorized Credit Card Holder)
Signature: ______________________________________________
Date: __________________
(Patient)
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140 Allen Road, Suite 300
Basking Ridge, NJ 07920
Phone: (908) 580-1200
Fax: (908) 580-1201
Email: ,
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Parent category: Business