Pre-Authorization Form

The Geivelis Group

06 W. Bartlett Avenue Bartlett, IL 60103-4235

1(630)830-4930

Card Holder Name

Exp Date

Card Number

Zip Code

Card Type

I authorize The Geivelis Group to keep my signature on file and to charge the credit card specified above in the event that my insurance reimburses me instead of Dr. Geivelis for services I have not been made liable.

Charges for the following family members:

Authorized Family Member

Card Holder Name

Card Holder Address

City

State

Zip

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

Date

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