Credit Card Authorization

Please complete all fields. You may cancel this authorization, but further appointments will not be scheduled without a credit card on file. This authorization will remain in effect until cancelled.

Credit Type:(Required)

MasterCard

VISA

Discover

AMEX

Other

Cardholder Name (as shown on card):(Required)

Card Number(Required)

Expiration Date (mm/yy):(Required)

Cardholder ZIP Code (from credit card billing address):(Required)

Name(Required)

First Last

Email(Required)

Phone(Required)

I, authorize to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transaction on my account.(Required)

Please Initial

Credit Card Authorization Form

Credit Card Authorization

Credit Card Authorization Form

Clearwater

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