Card authorization

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Authorization
Name on the card
Billing Address
Billing Address
City
State
ZIP

Acknowledgement

I hereby grant IAM Clinic permission to charge and store my credit card information for medical services provided. I confirm that the provided credit card and billing address details are complete and accurate.

By selecting the 'I Agree' option, I consent to the use of electronic records and signatures. I acknowledge that I have reviewed and agree to the terms and conditions, the privacy policy, and the telehealth consent outlined by IAM Clinic.