Page 22 - HSP-Assure Test Booklet FDA Auth Booklet - FINAL 8_2020

Credit Card Authorization Form

Credit Card Type: Circle One

Card Number: ____________________________________________________________

Expiration Date: _______ / 20 _____

CSV #: _______

Name on Card: ______________________________________________________________

Billing Address: ______________________________________________________________

Suite / Building #: ______________________________________________________________

City: _________________________ State: _______________ Zip: ___________

I hereby authorize Hensler Surgical to charge my credit card to collect my payments:

Signature: ____________________________________________________________

Name: ____________________________________________________________

Title: ____________________________________________________________

Date: ____________________________________________________________