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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“

First & Last Name *
Email*
Phone*
Price*
Please List The Procedure Payment Amount Sent To You In Your Bill From El Paso Cosmetic Surgery
Please List Your Full Name & Which Service You Are Paying For *
Authorization*
- 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.
Authorization*
- I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
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