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ULTRASOUND CC AUTH

CREDIT CARD INFORMATION

By submitting this form, I authorize Progressive Medical to charge my credit card in the amount of $75 in the event that a no-show/late cancellation fee is incurred for my ultrasound appointment or to be applied toward my account if there is a balance for this service that reaches a past due status of over 90 days. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds with the terms indicated above.

Type Name of Cardholder
* Required field