EmailMe Form - CREDIT/DEBIT CARD AUTHORIZATION

Name *
First Last
Legal name as on government issued identification.
Date of Birth *
MM / DD / YYYY
Please enter the patient's Date of Birth
Billing Address *

Street Address City State / Province / Region Postal / Zip Code

Please enter the address that is on file with the card.
Cardholder Phone Number *
### - ### - ####
Email *
This will be used for mailing any electronic documents/itineraries.

Confirm
Payment Details
Please provide payment details below
Credit Card *

Card Number

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Authorization of Charges *
I do authorize
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Vitality Physicians Group Practice PC in writing of any changes in my account information or termination of this authorization. It is expressly understood that the amount charged does not include or constitute any additional fees related to our acceptance of credit cards as a form of payment, permitted by law. I understand that patient services will only be issued upon receipt of payment for any amount due. I certify that I am an authorized user of this credit/debit card and will not dispute these scheduled transactions with my bank or credit card Company; so long as the transactions correspond to the terms indicated in this authorization form.
Signature *
Clear

Payment Details