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Home » Patient Resources » Forms » Credit Card Authorization Form

Credit Card Authorization Form

Please fill all required fields *.

Credit Card Authorization Form

  • I authorize Center for Bariatric Endoscopy to keep my signature on file and to charge my credit card account as indicated below:
    • • Please note, the card provided must be a CREDIT CARD, not a debit card, to avoid problems related to non-sufficient funds transactions.
 

Verification

 

“Individual results may vary.  Results are not guaranteed with this or any other procedure. Any weight loss procedure should be accompanied with nutritional counselling and an appropriate diet and exercise program.”