Credit Card Authorization

Date

Credit Card Information

Name (As It Appears on the Card)

Patient's Name (If Different than Card Holder)

Cardholder's Billing Address

City

State

Zip Code

Contact Phone Number for Cardholder

Credit Card Type

VISA

American Express

MasterCard

Credit Card Number

Expiration Month

Expiration Year

CVV (FOR VISA & MC BACK OF CARD)

CID (FOR AMEX FRONT OF CARD)

Amount to Charge

**I authorize Charm City Optical to charge my Credit/Debit Card for the total amount listed below. I acknowledge and understand that my order and all sales from Charm City Optical are final and no refunds will be issued.

Cardholder's Signature

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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