Bank Transfer Authorization Form

Please correct the errors described below.

I authorize Burgess Pediatrics to electronically debit my bank account for membership and vaccination fees on a recurring basis according to the terms of the membership agreement and as outlined below:

Terms of Recurring Billing:

Bank Account Information

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.

Your information will be encrypted.