Credit Card Authorization

Complete this form to authorize Northgate Dental to charge your card for treatment, copays, or a payment plan. Return it to our front desk or billing office.

Card details handled securely — full number & CVV never stored on this form

1 Cardholder

Name on card

Jordan A. Lee

Billing email

[email protected]

Phone

(555) 318-2204

Billing address

418 Maple Ridge Dr, Apt 6

2 Card details

Card number — provided securely

•••• •••• •••• •••• Captured securely by phone or encrypted link — do not write here

Card type

Visa

Last 4 digits

7742

Expiration (MM/YY)

08/27

Billing ZIP

94110

3 Amount & schedule

Amount to charge

$340.00

Charge frequency

One-time

This charge is for

Crown — patient balance after insurance

If a payment plan, how often — check one

One-time only Monthly until paid Per visit

4 Authorization

AUTHORIZATION TO CHARGE

I authorize Northgate Dental to charge the credit card identified above for the amount and on the schedule indicated. I certify that I am the authorized cardholder and that the information provided is accurate.

This authorization remains in effect until I cancel it in writing. I understand I may revoke it at any time by notifying the billing office, and that revoking it does not relieve me of amounts already owed.

I have read and agree to the authorization above.

Jordan A. Lee

Cardholder signature

June 17, 2026

Date

Northgate Dental · Billing Office · This form is kept confidential and stored securely.