I confirm that I am the cardholder listed above. I authorize payment to the office of Robert Rosenkranz DDS PC with the credit card listed herein. I attest that the information I have provided is correct and I approve the processing of this payment.
I hereby authorize this company to debit my bank account through the electronic Automated Clearing House (ACH) network within one to three business days from the date of this payment. I am aware that in the event this company is unable to secure funds from my bank account for this transaction for any reason, including but not limited to, insufficient funds in my account or insufficient or inaccurate information I provided when I submitted the electronic payment, further collection action may be undertaken by this company, including application of returned check fees to the extent permitted by law. If the payment is returned by my bank, I am still responsible for making a payment to this company.