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Credit Card Authorization For Payment

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 – Tempe

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:

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:

Master Card

Visa

AMEX

Discover

Credit Card Number:

Expiration Date (MM/YY):

Credit Card Source Code:

Card Holder Print Name:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

June 30, 2020 5:04 am MST

Credit Card Authorization For Payment Uploaded by Won-Woo Park - forms@ooliortho.com IP 70.163.243.141

April 1, 2023 4:16 pm MST

OoLi Team - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

April 1, 2023 4:16 pm MST