Payment Plan Form

This consent is valid for TWO years unless it is cancelled through written notice by the cardholder. After two years, a new credit card consent form will need to be filled out.

Patient Name:

Account Number:

I authorize DuPage Pediatrics, Ltd. to charge my credit card as listed below.

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

Cardholder Signature:

Date:

Cardholder Name as Listed on the Credit Card

Cardholder Address:

Contact Phone Number:

Credit Card Number:

Expiration Date:

Type of Card:

Dollar Amount:

Frequency of Charge:

Processing Date Each Month:

Current Balance

Please check this box if you wish to have any new balances charged once your current balance is paid off. The consent is valid for two years.

Please check this box if you only wish to pay off the current balance.

Your information will be encrypted.