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I authorize El Portal Imaging to process the above payment of $. I also authorize El Portal Imaging 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 El Portal Imaging prior to the payment date.

I authorize El Portal Imaging to process the payments as outlined in the payment schedule. I also authorize El Portal Imaging 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 El Portal Imaging prior to the payment date.

Thank you for using our convenient online payment center. If you have questions or need assistance please call our office at 1-209-384-4252.

El Portal Imaging
3365 G Street Suite 100
Merced, CA 95340

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