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The pdf version can be downloaded here.

Credit Card Authorization Form

The office requires that patients and families keep a credit card on file as a back-up payment method in the event of bill non payment and missed appointments that were not canceled 48 hours (two business days) in advance of scheduled appointment time. If you have not indicated a request to make payments in an alternative form, your card will be charged automatically at the time of the session. 

By signing below I grant permission to F. Tuna Burgut, MD to bill my credit card as per parameters outlined above. 

Thanks for submitting!

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