Credit Card Payment Authorization Form

Sign and complete this form to authorize the Center for Reproductive Health & Gynecology to make a debit to your credit card listed below.

By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date.

Please complete the information below:

Full Name *

I authorize the Center for Reproductive Health & Gynecology to charge my credit card account indicated below for: *

On or after: *

This payment is for: *

Billing address *

City *

State *

Country *

Postal code *

Phone *

Email *

Credit Card Information

Account type *

VISA

Mastercard

AMEX

Discover

Cardholder name *

Account number *

Expiration date *

Card identification number *

Signature *

Clear

Today's Date *

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.