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

Clearwater

International Plaza Tampa

Miami

Orlando

Credit Card Authorization

Clearwater

International Plaza Tampa

Miami

Orlando

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