Payment Plan Form

DuPage Pediatrics, LTD

Please correct the errors described below.

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.

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.

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