Name: DR. VALAIE, MD
Address: 1601 Dove St. #125, Newport Beach, CA, 92660, US
Telephone: (949) 225-0101

Credit Card Authorization Form
I Cardholder's First Name* Cardholder's Last Name* agree to pay $ Amount* for the treatment of Mr./Ms. Patient's First Name* Patient's Last Name* , who is my spouce, daughter, etc* using my credit card ending in last 4 digit of cc* .

Thank you.
Upload Cardholder's Photo ID*
Patient's Name*

First NameLast Name
Patient's email address*
[email protected]
Cardholdet's Name: *

First NameLast Name
Cardholder's Signature*

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Credit Card Authorization

Credit Card Authorization Form