Bank Transfer Authorization Form

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:

Membership Start Date:

Please select:

Annually Monthly

Bank Account Information

Account Holder Name:

Routing Number:

Account Number:

Billing Address:

Zip:

Billing Phone:

Billing Email:

This payment authorization is to remain in effect until I, notify Burgess Pediatrics in writing with 30 days notice of my wish to terminate my membership.

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.

Signature/ Name:

Date:

Please select:

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

Your information will be encrypted.