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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