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Payment Capture


Next Steps: Install a Payment Add-On

To accept donations via this form you will need to install one of our payment add-ons. To learn more about your payment add-on options, visit the following page ( Important: Delete this tip before you publish the form.
Patient Name(Required)
MM slash DD slash YYYY
Billing Information(Required)
Credit Card(Required)
American Express
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date

Authorization Agreement

I hereby authorize my bank to deduct from my bank account this one-time payment of my The Eye Center bill as indicated above. The Eye Center will note this transaction on my account until funds are secured from my banking institution. In the event The Eye Center is unable to secure funds from your bank account for this transaction for any reason, including but not limited to, insufficient funds in your account or insufficient or inaccurate information provided by you when you submit your electronic payment, further collection action may be undertaken by The Eye Center including application of returned check fees to the extent permitted by law. AGREEMENT: By clicking 'Submit,' you are agreeing to the above Terms & Conditions.

Credit Card

Replace this field with a field specific to your payment gateway whenever possible.