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Credit card authorization form

Credit Card Authorization Form

 

This is a request to receive a Credit Card Authorization Form. Once you have submitted your name, please allow our office two business days to send you our Credit Card Authorization Form. This Form will be sent through our HIPPA compliant messaging system, KLARA. We will not accept card information over the phone, over text, or by email as those are not secure ways to send personal information. For information on how to use, access, or set up KLARA, please contact our office.

Patient Name
Patient Name
 

If you would like to pay with cash or check, you may Either mail it to our office or drop it off in person.