Credit Card Authorization Form

Patient First Name

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Patient Last Name

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I authorize Advanced Women’s Health to charge my credit card below for any kind of violation stated in The Patient Care Agreement Form. I understand that my information will be saved to file for future transactions on my account.

Credit Card Information:

Card Type:

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Other:

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Cardholder Name {As shown on Card}:

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Card Number:

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Expiration Date {mm/yy}:

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Card Security Code {On Back}:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date:

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