On Site Dental Care

Date:

I hereby authorize Onsite Dental Care to keep the following credit card on file for account payment. No charges will be placed on this card without an email being sent to me stating the amount to be charged.

This authorization will stay in effect until written cancellation is sent to Onsite Dental Care.

Patient:

Patient account number:

Responsible Party:

Credit Card Number:

Expiration Date:

Security Code:

Patient or Responsible Party

Date

Onsite Dental Care Representative

Date