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I authorize University Pediatric Dentistry to process the above payment of $. I also authorize University Pediatric Dentistry to store this information in compliance with payment processing regulations and to charge the card listed above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact University Pediatric Dentistry prior to the payment date.

I authorize University Pediatric Dentistry to process the payments as outlined in the payment schedule. I also authorize University Pediatric Dentistry to store this information in compliance with payment processing regulations and to charge the card above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact University Pediatric Dentistry prior to the payment date.

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