CREDIT CARD AUTHORIZATION FORM
Please print this page (or download and print), fill in the required information and send with your denture. Or you can authorize over the phone after the denture is received. We can bill you through PayPal no credit card information required.
Card Type (circle one) : M/C VISA PayPal
Card Number: __________________________________________________
Expiration Date: _______/_______/________
Card Holders Name:_____________________________________________
(exactly as it appears on the credit card)
Billing Address: _________________________________________________
City__________________________________________
State __________________ Zip __________________
Card Holder Phone Number: ( )________-______________
Charge Amount: ____$59 Denture repair ____$99 Duplicate denture (check service)
Authorization Code: _____________________ from the back of the card
Shipping Address (if different than billing address):
_______________________________________________
City _______________________________ State _____________ Zip __________
Card Holder Signature:______________________________________________________
Card Holder Name (PRINT):__________________________________________________
Date Of Signature:_____________/_____________/_____________
