Credit Card Authorization Form
Please complete all fields.
You may cancel this authorization at any time by contacting us.
This authorization will remain in effect until cancelled.
PHONE: 770-559-8725
FAX: 770-559-8276
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  • If unknown enter date of service.
  • By submitting this form I authorize Prime Surgical Associates to charge my credit card for the above agreed upon amount. I understand that my information will be saved to file for future transaction on my account.