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
Credit Card Number *
Expiration Date *
Billing Zipcode *
Authentication number *
Please type your name in the box to give authorization for charge to your credit card once pre-purchase exam is complete. *