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Credit Card Authorization Form
Patient Name
(Required)
First
Last
Is the patient under 18?
(Required)
Yes
No
Guarantor Name
(Required)
First
Last
The guarantor is always the patient unless the patient is an incapacitated adult or an unemancipated minor (under age 18), in which case, the guarantor is the patient's parent or legal guardian.
Credit Card or FSA/HSA Card Number
(Required)
Please enter a number less than or equal to
16
.
Expiration Date
(Required)
Zip Code
(Required)
CVC
(Required)
Consent
I consent to the Credit Card Form Terms Below
Credit Card Form Terms:
I authorize Millennium Eye Center to charge the credit card indicated in this form to collect payment for services and products recieved at Millennium Eye Center. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
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