Initial payments for orthodontic treatment must be made by cash, check or credit card in person. Your subsequent monthly payments may be made by automatic monthly credit card payments.

I hereby authorize

OoLi Orthodontics – Phoenix

to charge my credit card for the professional fee for orthodontic treatment for the patient noted below. The issuer of this card is authorized to pay the amount (together with any other charges due there on) subject to and accordance with the agreement covering the use of such card.

Name of Patient:

Name of Card Holder:

Billing Address:

City, State, Zip Code:

Telephone:

Email:

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Authorized Payment Amount:
$ for months.

Payment will be deducted on the first business day of each month. If first on Friday, Saturday, or Sunday we will post on the last day of the previous month.

Credit Card Type:

Credit Card Number:

Expiration Date (MM/YY):
010203040506070809101112 23242526272829303132333435363738394041424344454647484950 
Credit Card Source Code:

Card Holder Print Name: