Dear Dr. Pollak DMD PC,

I, , hereby authorize Dentist at your door to keep the following credit card on file for account payment. No charges will be placed on this card without an email being sent to me stating the amount to be charged.

This authorization will stay in effect until written cancellation is sent to Dentist at your door.

Patient Account Number:

Credit Card Number:

Expiration Date:

Security Code:

Zip Code:

Date: