Payment Authorization If you would like to print and fill out a PDF version of this form please click here. Otherwise fill out the form below. THIS FORM MUST BE COMPLETELY FILLED OUT AND SENT TO OUR OFFICE 48 HOURS PRIOR TO YOUR SURGERY DATEPayment Processing(Required) I, hereby authorize Dr. James Gift to process payment for my treatment via my credit/debit card. Credit Card Type(Required)American ExpressVisaMatercardDiscoverCare CreditCredit Card Number(Required) Expiration Date(Required) Month and Year RequiredSecurity Code (V-Code)(Required) Billing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Processing Date(Required) MM slash DD slash YYYY 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 Select files Max. file size: 2 MB.