AUTHORIZATION TO CHARGE CREDIT/DEBIT/CHECK CARD:

Total Amount Due: $ ______________

Total Monthly Charge:$____________

Total amount authorized to charge to credit card: $__________

I, ____________________________ , give permission for

Dr._________________ to charge the above amount of $ __________ monthly not to exceed, $ __________ .

I understand that I am responsible for all charges regardless of the outcome of my insurance claim.

___________________________________________ ____

__________________

SIGNATURE OF CARDHOLDER DATE