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 DATE

Payment Processing(Required)
Month and Year Required
Billing Address(Required)
MM slash DD slash YYYY
Name of Cardholder (If Different From Patient)
If you have trouble uploading here please email it to ddstampa@ddstampa.com
Drop files here or
Max. file size: 2 MB.
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