Credit Card Info

3025 E. Commercial Blvd
Fort Lauderdale, FL
+19547710902

Recurring Payment Authorization Form

Schedule your payments to be automatically withdrawn from your account. Just complete and sign this form to get started!

Recurring Payments Will Make Your Life Easier:

It’s convenient (saving you time and postage)
Your payment is always on time (even if you are out of town), eliminating late charges

Here’s How Recurring Payments Work:
You authorize regularly scheduled charges to your Visa, MasterCard, American Express, or Discover card. You will be charged each billing period for the total amount due for that period. Unless otherwise indicated, the billing amount and scheduled date of the previous form (if applicable) will remain the same.

Please complete the information below:

Iauthorize Benedetti Orthodontics, to charge my account indicated below on theof each month for payment of my/my child(s) orthodontic treatment.

Name Of Patient:

Billing Address

City, State, Zip

Billing Amount:

Phone#

Account Type (check all that apply):

Cardholder Name

Card Number

Expiration Date

CVV (3 digit number on back of Visa/MC, 4 digits on front of AMEX)

*Please note: Three (3) missed auto payments will terminate the privilege for the responsible party to finance in-house and will result in full payment being rendered for entire balance on account immediately.

Signature

By signing, I authorize the above named business to charge the account indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.