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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:
Your answer
Billing address:
Your answer
Credit Card Type:
Expiration date:
MM
/
DD
/
YYYY
CVC or code: (last 3 digits located on the back of the credit card)
Your answer
Amount to Charge (in USD) one time
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