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  • Mid South Dermatology - Credit Card Authorization Form

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    This form is for all patients seeking payment through an account.

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    © All Rights Reserved
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    90 views1 page

    Mid South Dermatology - Credit Card Authorization Form

    Uploaded by

    jtderm
    This form is for all patients seeking payment through an account.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Mid-South Dermatology & Skin Cancer Center

    6570 Stage Road, Suite 140


    Bartlett, TN 38134
    (901) 372-4545

    AUTHORIZATION FOR CREDIT CARD PAYMENT


    VIA FACSIMILE # (901) 372-4310
    ATTENTION: SYLVIA

    DATE:

    ___________________________________

    PATIENT: ___________________________________
    ACCOUNT #: _________________________________
    VISA _____MC______ DISCOVER_____AMEX______
    #___________________________________________
    EXPIRATION DATE: ________/________
    CVV ________
    Contact phone number for questions _______________

    How should we handle your receipt?


    SHRED __________
    MAIL TO ADDRESS ON ACCOUNT _______

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