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Credit Card Authorization Form

Auto Pay

To simplify the management of your account, we offer automatic payments via Visa, Master Card or American Express. If you choose to take advantage of this payment option, we must have authorization to process the charge. Complete this authorization form to setup your automatic payments.

Your credit card can be processed by either option:

  1. Automatically process account balance on the statement date.
  2. Automatically process account balance on the 5th of each month unless I contact Peterson Dental Laboratory with a discrepancy on my statement.

Please complete the pre-authorization form to utilize this method of payment. Select which processing option works best for you. Contact our Accounts Receivable Department with questions for additional information.

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PREAUTHORIZATION FORM: VISA, MASTERCARD or AMERICAN EXPRESS

All information must be completed to process card.
(Practices with multiple locations, accounts, or dentist)
Address
City
State
ZIP
Options(Required)
TYPING YOUR FULL NAME IN THE FIELD BELOW CONSTITUTES A BINDING SIGNATURE ON THIS DOCUMENT
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