Payment Form

Sleep Medicine Consultants

Telephone 512-420-9900

First and Last Name

Date of Birth

Payment Amount

Credit Card Number

Expiration Date

Security Code

Address, City, State, Zip

Email Address

I authorize Sleep Medicine Consultants to charge the credit card indicated in this authorization form for the amount indicated above. This payment is valid for one (1) time use only. I certify that I am an authorized user of this credit card.

Electronic signature

Date

Once the transaction is completed you will receive an email with a copy of your transaction receipt.

Your information will be encrypted.