Client Credit Card Information & Authorization Form
**This form is ONLY to pay for Client Occupational Invoices. If you are trying to pay a balance for primary care please call 702-733-6622 ext 206**
Last 3 Numbers
Only VISA or MASTERCARD
Month/Year
CVV
Billing
I certify that I am an authorized user and/or owner of the credit card referenced above. I authorize A Nicknam PC DBA Southern Nevada Occupational Health Center to charge the credit card and apply the payment(s) to the invoice(s) listed.
First & Last Name
Thank you for your payment. Payments submitted after 1:30 pm will be processed the next business day.