Payment Authorization

Payment Processing(Required)

I, hereby authorize Dr. James Gift to process payment for my treatment via my credit/debit card.

Credit Card Type(Required)

Credit Card Number(Required)

Expiration Date(Required)

Month and Year Required

Security Code (V-Code)(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Preferred Processing Date(Required)

Patient First Name(Required)

Patient Last Name(Required)

Phone(Required)

Email(Required)

Patient Account # (If Applicable)

Name of Cardholder (If Different From Patient)

First Last

You must attach a copy of the cardholder's state issued ID or Driver's License (front and back).

If you have trouble uploading here please email it to ddstampa@ddstampa.com

Drop files here or

Max. file size: 1 GB.