Credit Card Authorization Form printable pdf download

Credit Card Authorization Form

Shawn A. Khavari, MD PLLC

3917 E. Covell Rd

Telephone: 405-471-5557

Edmond, OK 73034

Fax: 405-471-5571

CREDIT CARD AUTHORIZATION FORM

THIS FORM MUST BE COMPLETED ENTIRELY, DO NOT LEAVE BLANKS

Patient Name: ____________________________________________________

Your Name: ______________________________________________________

Relationship to Patient: _____________________________________________

Credit Card Number: _______________________________________________

(WE ONLY ACCEPT VISA OR MASTERCARD)

Expiration Date: ___/____

CV Number: _____________

Billing Address: ___________________________________________________

I understand that the credit card mentioned above will be used to pay the balance in full on this

account.

__I would like to be notified when you charge my card.

__By Phone

Phone Number __________________________________

__I do not want to be notified when you charge my card.

Signature: ________________________ Date: ___/____/____

Please include a legible copy of the front and back of your credit card and the front of

your driver’s license.

****If you have questions please call our office****

Credit Card Authorization Form