Credit Card Authorization
M.A.Gutierrez DDS, PA
Orthodontist for Adults and Children
I hereby authorize the office of Dr. Gutierrez to automatically draft the identified credit card in the amount of $
per month. This amount represents the monthly payment amount as stated in the signed contract. I understand that drafts will begin on
and will continue for
months or until all contract charges have been completed.
In addition I authorize a one time draft of $
to be charged to said card on
and applied to the initial payment due.
I further understand that I may cancel the request for automatic drafts by coming into the office and signing a release form. The remaining monthly installment must be paid in full by money order, credit card or cash with no penalty.
There will be a service charge of $25.00 for each declined transaction and a late fee of $40.00 will be applied after 5 days past due.