Credit Card Authorization Credit Card Authorization Step 1 of 3 33% CREDIT CARD AUTHORIZATION AND RECURRING PAYMENT FOR PURCHASES FORM This form grants AxioBionics, LLC authorization to charge the patient’s credit card for the indicated service/device. All requested information is required. Upon approval, we will bill your credit card for the amount indicated and your total charges will appear on your credit card statement. Any changes to your credit card information must be communicated to AxioBionics in a timely manner. Your credit card may be charged for: 1) One-time purchases or trials, 2) Recurring purchases, or 3) Automatic recurring billing for rented or trial equipment. TERMS OF SERVICE FOR RENTAL, RENT-TO-PURCHASE, AND NON-RETURNABLE ITEMS: Borrower shall be responsible for proper use of the equipment. Borrower is responsible for the full cost of repair or replacement of any or all equipment that is damaged, lost, or stolen from the time borrower assumes custody until it is returned to AxioBionics. Borrower shall be responsible for the safe packaging and shipping, if needed, of the equipment. If equipment is not returned within 7 days after end date of trial period, borrower shall be charged an additional month of rental. Borrower will incur additional rental charges for each month thereafter until equipment is returned. AxioBionics reserves the right to charge the full purchase price of any equipment not returned. An extension of the trial period must be coordinated with AxioBionics prior to the original end date of the trial period. Equipment shall be returned to: AxioBionics, 6111 Jackson Rd. Suite 200, Ann Arbor, MI 48103.PATIENT INFORMATIONPatient Name (print) First Middle Last Patient # (Office Use) Authorized Representative (print) Relationship to Patient PAYMENT INFORMATIONService/Device Description Serial # Trial or Rental Start Date MM slash DD slash YYYY Trial or Rental End Date MM slash DD slash YYYY Total Amount Recurring Payment Amount Frequency: N/A Monthly FIRST PAYMENT ON: MM slash DD slash YYYY Start Date (month/day/year)LAST PAYMENT ON: MM slash DD slash YYYY End Date (month/day/year) No End Date CREDIT CARD INFORMATIONCard Type: MasterCard VISA Discover American Express Card Holder’s Name (as shown on card) Credit Card Billing Zip Code ZIP / Postal Code Card Number Expires On (month/year) Card Security Code (CVV) Card Holder’s Email Card Holder’s PhoneConsent I (patient/authorized representative) grant AxioBionics, LLC authorization bill the credit card listed above as specified.Patient or Authorized Representative (print) Patient or Authorized Representative SignatureDate MM slash DD slash YYYY Consent Verbal Authorization granted by Card HolderAxioBionics Representative Date MM slash DD slash YYYY
