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.
Cardholder Name (as shown on card)
Encrypting form data.
What is this?
3 or 4 digit number printed on the back/front of your credit card
Protected in vault
Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Cardholder ZIP Code
Amount to be charged
Date of Birth
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.