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

Billing email

Phone

Billing address

2 Card details

Card number — provided securely

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

Card type

Last 4 digits

Expiration (MM/YY)

Billing ZIP

3 Amount & schedule

Amount to charge

Charge frequency

This charge is for

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.

Cardholder signature

Date

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