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Your
debit or credit card has been charged for
professional services provided to you as follows: Type
of Card: VISA, MasterCard
or.Discover |
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| Date of Service ___________ | _____________________________ | |||
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Card Holder Name | |||
| Type of Service __________________ | ||||
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| Total Charged $___________ | _____________________________ | |||
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Authorized User, if different | |||
| Services Provided by: | ||||
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| Name ___________________________ | _____________________________ | |||
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Card Number | |||
| Address _________________________ | ||||
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| ________________________________ | ______________ | |||
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Expiration Date | |||
| ________________________________ | ||||
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| Phone ___________________ | ______________________________ | |||
| Signature of Patient or Card Holder | ||||
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| I acknowledge receiving the above service, and authorizing provider to charge my debit or credit card. | ||||
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| Notice: | ||||
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These charges will appear on your monthly card statement as |
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ProfessionalCharges.com |
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and not the name of your provider or the services rendered. |
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