Credit Card Voucher

[Guest guest]

I know they have paper versions one can buy, but I like having one available of my own.

This is a Credit Card Voucher for when the credit card machine is down.

Allows the front desk to write down the info and enter the charge in later when the credit card machine is up and running.

Anything you would add?

Credit Card Payment Voucher

Date: _____-_____-_____ Account #: ___________________________

Patient Name: ____________________________

Name on Cardif Different: ________________________________

Card Holder Mailing Address:

__________________________________ City: ______________ Zip: _________

O Visa

O MstrCrd

O DiscoverO AmEx

Amount Paid: $____________.______

Mail Receipt?

O Yes

O No

Card Number: __________ __________ __________ __________ Exp Date: _____ / _____

Signature: ___________________________________________________ Date: _____-_____-_____

LFM Staff Initials: ____________

Locke, MD