Credit Card Authorization Form

authorize Rashin T. Bidgoli, DMD, PC to charge my credit card below for the agreed upon services rendered. I understand that my information will be saved to file for future transactions on my account if needed.

Credit Card Information

Card Type:

MasterCard Visa Discover AMEX CareCredit

Cardholder Name (as shown on the card):

Card Number:

Expiration Date:

Billing Zip Code:

CVC (security code):

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.

Patient/Guardian Signature:

Date:

Your information will be encrypted.