PREAUTHORIZED CREDIT CARD FORM

Burgess Pediatrics, Inc.
401 Burgess Drive, Suite C,
Menlo Park, CA 94025-3408

For contract/billing questions contact
Leigh Phillips at leigh@burgesspediatrics.com
or call (650) 305 2039

Patient Name(s):

I authorize Burgess Pediatrics, Inc. to bill the card listed below as specified:

per month per patient per year per patient

By choosing to use a credit card instead of bank debit via ACH, I accept a 3% credit card surcharge on each payment.

Start billing on:

End billing when:
30 days after patient provides written cancellation

Credit Card Type:

Visa MasterCard American Express Discover

Card Number:

Expiration Date:

CVC:

Cardholder Name:

Billing Address

City:

State:

Zip:

Billing Phone:

Billing Email:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Cardholder Signature:

Date:

Dr. Sarah G. Cueva Dr. Margaret Miller Dr. James A. Cisco

Your information will be encrypted.