Payment Authorization Form

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Palm Beach Stem Cell 824 US Hwy 1 Suite 110 North Palm Beach, Fl 33408

Credit card payment form

Type of Card:

Card Number:

Name on Card:

Expiration Date:

Security Number:

(The last 3 numbers on the back of card, or last 4 on front for AMEX) Billing

Address:

Amount:

Reoccurring :

Reoccurring Terms:

authorize Palm Beach Stem Cell to charge my credit card above for

agreed upon purchases. I understand that my information will be saved on file for future transactions on my account. Authorization will remain in effect until cancelled.

Signature:

Date

The form was sent successfully.

An error occured.

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[field id="Card-Number"]

[field id="Name-on-Card"]

[field id="Expiration-Date"]

[field id="Security-Number"]

[field id="Address"]

[field id="Amount"]

[field id="Reoccurring"]

[field id="Reoccurring-Terms"]

[field id="agreed"]

[field id="Date"]

Thank you for the opportunity to be of service!

Regenerative medicine is now at the forefront of helping every day people overcome injuries, illness, and aging, without the need for surgery or invasive measures.

Payment Authorization Form

Credit card payment form

(The last 3 numbers on the back of card, or last 4 on front for AMEX) Billing

Thank you for the opportunity to be of service!

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