Payment Authorization Form Doctor Office I prefer to have my weekly charges be processed as: ACH Payment Credit Card Payment ACH Payment Details (no additional fees) Checking Savings Account Name Bank Name Account Number Routing Number Credit Card Details Visa Mastercard Discover Amex Credit Card Number Exp. Date CVV Code Name on Card Billing Address I hereby authorize Hero Dental Lab, to charge my credit/debit card or run my ach payment each month on the 5th. The amount processed will reflect all charges incurred for the previous month. E-Signature Date Send