Child's Name *

First Name

Last Name

Cardholder's Name *

First Name

Last Name

Phone

(###)

###

####

Payment Method *

Visa

Mastercard

American Express

Payment Agreement

I authorize Bloom Pediatrics, Inc. to charge the credit card above according to the following terms: I understand a 3% convenience is added to all credit card payments. I certify that I am an authorized user of this credit card, and I will not dispute the payment with my credit card company provided the transactions correspond to the terms indicated in this authorization form.