Payment Authorization Form

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What would you like to do

New payment method Update payment method

First Name

Last Name

Practice Name

Accounting Phone Number

Accounting Email

Payment information

Credit Card ACH

Billing Address

City

State

Zip Code

Credit Cart Number

Expiration Month

Expiration Year

CSV

Bank Name

Account Type

Account Number

Routing Number

* All credit card transactions will carry a processing fee of 3.5% per order.

I authorize Pipeline Medical to charge my credit card for the authorized amount. I understand that my information will be saved to file for future transactions on my account.

Signature

Name

Date of Signature