Telephone Credit Card Authorization

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Credit Card Authorization
Patient Name (MUST MATCH NAME IN OUR SYSTEM)*
Contact Number*
Email*
FCLV Account/Chart Number
Invoice Number
Amount due to FCLV (in USD)*
Please do not include the $ symbol. There must be an amount entered into the form, if no payment is to be made to FCLV, please type in the number 0 into the field above.
Amount due to Ovation Fertility (in USD)*
Please do not include the $ symbol. There must be an amount entered into the form, if no payment is to be made to Ovation Fertility, please type in the number 0 into the field above.
Cardholder Name*
First Last
Credit Card Number*
Expiration Date (Month/Year)*
CVV (Security Code)*
Cardholders Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I give The Fertility Center of Las Vegas/Ovation Fertility authorization to charge my credit card.*
- I agree
- I do not agree
Please Agree*
By submitting this form, you are confirming you have read and agree to our Terms and Privacy Statement and agree to be contacted by our office.
- Yes, I agree
Card Holder's Signature*
Date*
MM slash DD slash YYYY
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Date
MM slash DD slash YYYY

Credit Card Authorization