Card Authorization Form

Card authorization

Your connection is secure with SSL encryption.

Authorization

First name

Name on the card

Last name

Billing Address

City

State

ZIP

Billing Address

Card Number

Month:

Year

CVV

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.

Authorize

I agree to Terms and Conditions, Privacy Policy, and Telehealth Consent

Cardholder Signature

Clear

Date

Date of signing

If you are human, leave this field blank.