Credit Card Authorization Form - Axon Health Associates

Our office requests that a credit card be kept on file for payment of any co-payment, co-insurance, late cancel/no show, deductible and/or charges not covered by your health insurance. This form will be kept confidential and only authorized staff has access to the information.

Patient's Name:(Required)

First Last

Name As It Appears on Credit Card:(Required)

Credit Card Number:(Required)

Expiration Date:(Required)

CVV Code:(Required)

Billing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone:(Required)

Email:(Required)

Today's Date:(Required)