PSJ Orthodontics

Initial Authorization Form

Effective Date of Authorization:

Name of Patient:

Account Information

Responsible Party Name:

Billing Address:

Monthly Payments:

Choose the 1st or the 15th of each month to have payments automatically withdrawn.

1st

15th

Date of First Automatic Payment:

Amount of Monthly Payment:

Card Information:

Select Card Type:

Visa

Mastercard Discover

American Express

Name on Card:

Card Number:

Expiration Date:

VCode:

I authorize the above practice and Vanco Services, LLC to charge my credit card in accordance with the information above.

Signature

Date: