Credit Card Authorization Form
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Email *
Full Name *
Date of Birth *
MM
/
DD
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Last 4 of Social Security *
Purpose of Payment *
Billing Address *
Telephone *
Cardholder Name *
Credit Card Type *
Credit Card Number *
Expiration Date *
Security Code *
I hereby authorize Rotemberg Plastic Surgery, PLLC to use this card for the future deposits and for final payments. SIGN YOUR NAME TO CONSENT. *
A copy of your responses will be emailed to the address you provided.
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