PLEASE NOTE: Information on this form is immediately ENCRYPTED and stored
on a secure server, accessible only by logging onto the secure server with a 12 digit
password. YOUR FINANCIAL INFORMATION IS TOTALLY SECURE. We will
manually enter this information into a separate credit card processing software in our
office. If you have any questions regarding this process, please feel free to contact the
office manager, Lisa Willis, at 760-365-9878 or drjpfaxes@verizon.net. Thank you!

Please complete all fields! Thank you!

PATIENT Last Name: First Name:

Date of Birth: //

Account number (if known):

Amount to be charged: $ dollars . cents

Name exactly as it appears on credit card:

Credit Card Number:

Card Type: Please select Visa Mastercard Discover American Express Expiration Date: Please select January February March April May June July August September October November December Please select 2009 2010 2011 2012 2013 2014

Credit Card Security Code: