Payment Authorization Form

Please complete this secure form to authorize your payment.

Unless you advise us otherwise, we will use this payment method for your all of your one-time purchases and/or recurring payments.

Please note: Recurring monthly payments are processed on the first of each month for your ongoing services.

We typically recommend starting monthly marketing 2 months prior to opening a new practice or for an established practice, 1 month after commencing work with our team. Please list the month and year we'll start your monthly marketing services. This will allow our billing and fulfillment team clarity. Our team works ahead, this decision is not one that can be changed, please consider your marketing start date carefully. All monthly service fees are billed on the first of the month.

Also, for any hosting, domain, or other third-party services that you may have, you can ask us to update or assist in keeping your payment information updated.

Monthly Marketing Start Month:

Full Name

Business Name

Billing Address

Phone

Email

Cardholder Name (as it appears on the card)

Card Number

Expiration Date
Use the Format: MM/YYYY

CVV
4 digits on front of AmEx or 3 digits on back of MC, Visa, or Discover

Unless you advise us otherwise, we will use this payment method for all of your one-time purchases, deposits and/or recurring payments.

For Electronic Signature, please click in the box, then draw your signature with your mouse if on a desktop. Draw signature with your finger or stylus if using a mobile device such as phone or tablet.

Electronic signature
Please click in the box, then draw your signature with your mouse if on a desktop. Draw signature with finger or stylus if using mobile device such as phone or tablet.

Clear

Please Note:

By checking this box, you agree that if your billing or payment information changes, it is your responsibility to update this form.

Verification