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Credit Card Authorization Form

LifeBack
4 Princess Rd
Suite 206
Lawrenceville, New Jersey 08648
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Authorization Information
* Authorization Information
I am authorizing my card to be charged by LifeBack ONLY after a tele-health appointment.  
I am authorizing my card to be charged by LifeBack for ALL appointments.  
Credit Card Information
* Name on Card
* Type of Card    if selecting Other, please write type of card
Visa   Mastercard   American Express  
Discover   Other    
* Credit Card Number
* Expiration Date (MM/YYYY)
* Security Code
* Billing Address
* City, State, Zip Code
* Phone Number
* Email Address
* Authorized Card Holder Electronic Signature    By typing your name below you are confirming your electronic signature and authorizing LifeBack to charge your card on file for the services you selected above.
* Relationship to Patient    PLEASE WRITE "SELF" IF YOU ARE THE PATIENT
* Date
Form Updates
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