Credit/Debit Card Authorization Form

Credit Card Authorization Form

This form allows clients to put a credit/debit card on file so co-pays, deductible payments or self-pay payments can be charged to the credit/debit card after our billing staff verifies an appointment was attended.

If you are human, leave this field blank.

Client First Name *

Client Last Name *

Cardholder First Name *

Cardholder Last Name *

Billing Address *

City, State *

Billing Zip Code *

I hereby authorize Mesa Vista Wellness to process credit card payments from the company and the credit card named below. I understand that credit card payments will not be processed without authorization. Authorization shall be acknowledged by my signature below.

Credit/Debit Card Company *

Visa

Mastercard

Discover

American Express

Credit/Debit Card Number *

Expiration Date *

CVV Code *

Signature of Cardholder *

Clear

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Credit/Debit Card Authorization Form

Credit Card Authorization Form

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Credit/Debit Card Authorization Form

Credit Card Authorization Form

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