May River Dermatology

PH 843.837.4400 | FAX 843.837.4440

BLUFFTON
7 ARLEY WAY, STE 101 | BLUFFTON, SC 29910
350 FORDING ISLAND RD, STE 100 | BLUFFTON, SC 29910

HILTON HEAD ISLAND
25 HOSPITAL CENTER COMMONS, STE 200 | HILTON HEAD, SC 29926

PORT ROYAL
1813 RICHMOND AVE | PORT ROYAL, SC 29935

Carrie Hall, MD Joseph McGowan IV, MD Dale Sarradet, MD Carmen Traywick, MD
Amanda Medlin, PA-C Heather Casalicchio, PA-C Nicholas Cassel, PA-C
Jonathan Samaha, PA-C Emily Simpson, PA-C

Card on File Consent

For your convenience, we have implemented a policy which enables you to maintain your credit/debit card information on file with us. With your consent, this information will be securely held to cover future charges and additional fees.

Signing this consent in no way compromises your ability to dispute a charge or question your insurance company’s determination of payment.

I hereby authorize May River Dermatology, LLC to keep my Card information on file for payment of any and all charges for medical services for which I am financially responsible and that remain unpaid after two (2) statements have been mailed.

I understand that you will send me a receipt reflecting any amount charged to my Card.

If my card information changes for any reason, I will notify you. This consent shall remain in effect until I give you written notification of termination.

Agreed to:

Patient's Name*:

Patient's DOB *

Patient Signature:

Date:

VISA

DISCOVER

We currently do not keep American Express cards on file.

Credit Card #*:

Name as it appears on the credit card*:

Expiration Date (MM/YY): /

Security Code (3 or 4 digit # printed on front or back of card)*:

Street Address*

City*

State*

Zip Code*