Authorization

Name on card
First Name Last Name
Email*
Billing Address*
Street Address Address Line 2 City Province Postal Code
Credit card type*
- Visa
- Mastercard
- Discover
- Amex
Credit card number*
Expiry Date*
CVV*
Amount to charge (CAD)*
When to charge*
- One time only
- after every visit to clear balance
- Payment plan
I authorize King West Dental Studio to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.
Signature*
Print name*
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