Credit Card Payment Authorization Form

comodo_secure154x97Please click here to download a copy of the Credit Card Payment Authorization form, print and bring it with you to your appointment, or complete the form below and submit it electronically.

  • I hereby authorize Spring Valley Pediatrics P.L.L.C. to charge the credit card indicated below after my visit for the full payment. This information will be kept in a secure location. I understand that Spring Valley Pediatrics P.L.L.C. will charge my account within 72 hours of my child’s visit. I understand that this authorization will remain in effect until I notify Spring Valley Pediatrics P.L.L.C. otherwise. I understand that if I need to change my credit card information, I can do so by calling the Billing office at 202-966-1157
  • This field is for validation purposes and should be left unchanged.