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Credit Card Authorization Form- Pre-purchase exam
Payment for pre-purchase examinations is expected at the time of service.
Minimum charges will include $125 for a two stage or $250 for a four stage
exam plus a call fee of $20-$65 depending on location. Costs of further
diagnostics will be discussed and must be approved prior to their initiation.
If you can not be contacted during the visit, further diagnostics will not be
attempted unless previously agreed upon.
Pre-purchase exam:
*
two stage pre-purchase exam ($125)
four stage pre-purchase exam ($250)
See pre-purchase exams under Services
for details of two vs. four stage exams.
Name as it appears on the credit card.
*
Credit Card Type
*
Visa
Master Card
Billing Zipcode
*
Please type your name in the box
to give authorization for charge to your
credit card once pre-purchase exam
is complete.
*