One Time Credit Card Payment Authorization Form For A $100 Consultation Fee At El Paso Cosmetic Surgery

By submitting this form, you give El Paso Cosmetic Surgery Center permission to make a one time debit to your credit card of $100 fee for your Consultation. You give us permission to debit your account for the amount that we have indicated to you on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Enter your payment amount and information below For The $100 Consultation Fee. Once You Hit Submit You Will Be Prompted To Enter Your Payment Details.

By Submitting This Form For You Are Stating: “I understand this is a non-refundable consultation fee and in case of a no-show or cancellation within 24 hours of the consultation appointment, there will be a $100 rescheduling fee

  • Please List The Procedure Payment Amount Sent To You In Your Bill From El Paso Cosmetic Surgery
  • This field is for validation purposes and should be left unchanged.