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 Patient(s) Name(s)*Name as it appears on card* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* PhoneCredit Card Type*VisaMasterCardDiscoverAmerican ExpressCredit Card Number*CVV*Exp Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExp Year*20172018201920202021202220232024202520262027202820292030CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
