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Credit Card on File Authorization

Name
Initials
Signature
Date
MM slash DD slash YYYY
CREDIT CARD NUMBER
Expiration Date
CVV Code
Card Holder's Printed Name
Signature
Date
MM slash DD slash YYYY
Billing Address Associated with Card on File
Patient Name
Date of Birth
MM slash DD slash YYYY
Card Holder's relation to patient
Billing Address
Phone
City
State
Zip
Scanned date:
Staff initials:
System "Alert" added:

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