Credit Card Authorization Form in Lipan, TX - Champion Embryo Transfer Service

Billing & Payment Options
Only one authorization contract required per account
Billing Options*
- Paper Bill - Your summary statement will be mailed to you at the end of each billing period.
- Paperless eBilling - Your summary statement will be emailed to you at the end of each billing period.
- Both
Payment Options*
Credit card information is REQUIRED, regardless of the form of payment checked below.In order to provide the most security for your credit card information, please use our client portal (accessible through our website or from an ebill) or call our office at 817-599-5999 to put your credit card information on file.
- Pay by CHECK or CASH from your summary Statement
  If you choose to pay by cash or check, and payment is not received within 60 days of billing, we will charge your credit card for your balance. By filling out and signing the credit card authorization below, you authorize Champion Embryo Transfer Service to charge the balance on your account to the credit card provided.
- Pay by CREDIT CARD
  CETS will send summary statements via EMAIL and/or PAPER. After you have reviewed the charges, you may use a credit card to pay using the client portal or calling our office at 817-599-5999.
- CREDIT CARD on file with CETS
  For your convenience, you may use this form to pre-authorize charges. At the end of each billing cycle, we will charge your card on file and will send an email receipt of your payment along with your summary statement.
Name on account*
Billing Contact (if other than owner)
Billing Email*
Billing Phone*
Date*
MM slash DD slash YYYY
Signature*
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Comments
This field is for validation purposes and should be left unchanged.

Billing & Payment Options