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Credit Card Authorization

Please download, print out and fill out this form DOWNLOAD FORM

I hereby authorize H. Debra Jaliman, MD to process charges against my Visa/ MasterCard/American Express/ Discover.

Patient: ___________________________________________________

Date of Treatment: ___________________________________________________

Amount: ___________________________________________________

Name as it appears on card: ___________________________________________________

Account Number: ___________________________________________________

Expiration Date: ___________________________________________________

Issuing Bank for card: ___________________________________________________

Security Code: ___________________________________________________

I understand that these charges will appear on the statement of my credit card bill. I have also attached a signed and dated copy of my credit card front and back.

Signature: ___________________________________ Date: ___________________________________