Payment Form

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

Payment Authorization Form

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