Credit Card Authorization | Strash Foot & Ankle Care

I authorize the use of my credit card by Strash Foot and Ankle Care *

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Last

Credit Card Type *

Credit Card Number *

Expiration Date *

Credit Card Verification Number *

Card Holder Name *

Authorization *

By typing your name, you authorize Strash Foot and Ankle Care to use your card.

Date *

I understand that the amount charged to my credit card will be reflected on my credit card statement within seven days of authorization.