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Authorization for Credit Card Use
By Carpe Diem Concierge Medicine, LLC for Fees and Services
All information will remain confidential
Name on Card:
Billing address:
Credit Card Type:
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Credit card number
Expiration date:
MM
/
DD
/
YYYY
CVC or code: (last 3 digits located on the back of the credit card)
zip code on card
Amount to Charge (in USD)
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