• CREDIT CARD PAYMENT AUTHORIZATION

    By signing this form, you are giving permission to Edward Gottesman, DDS, PC to retain this credit card on file to charge your account per your approval.

  • CARD DETAILS:

  • Expiration Date

  • I authorize Edward Gottesman, DDS, PC to charge the credit card indicated on this authorization form. I certify that I am an authorized user of this credit card.