PH 470.282.5729 | FAX 770.674.5795
JOHNS CREEK
10680 Medlock Bridge Rd., Suite 204 | Johns Creek, GA 30097
Dr. Paola Bonaccorsi | Dr. Dale Sarradet 
 
 
 

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 Signature:


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