|
Dear
Dr. _______________________,
This
states you were referred to me by one of the above websites (please circle website). TopSurgeonsOnline will pay $50 of my consult or surgery. Just fax this form for a credit card payment.
Signed
________________________________ Date _______________________
| Patient Name
|
_____________________________________ |
|
Address
|
_____________________________________ |
| City,
State |
_____________________________________ |
| Email |
_____________________________________ |
| Consult Date |
_____________________________________ |
| Surgery Date |
_____________________________________ |
I verify the above patient has consulted with me after being referred by the above circled website. Patient has paid in full minus $50. My account with TopSurgeonsOnline is up to date.
Doctor's Signature ____________________________ Date __________________
Please Make $50 Payment to:
| Practice Name |
_____________________________________ |
| Doctor |
_____________________________________ |
| City,
State |
_____________________________________ |
| Fax |
_____________________________________ |
Fax
980-225-0475 for Credit Card Payment
or mail to: TopSurgeonsOnline, 4817 Parker Drive, N. Charleston, SC 29405
Check available upon request.
Payment Info to be Faxed back to Surgeon's Office
| Name on Card: |
_____________________________________ |
| Visa #: |
_____________________________________ |
| Expiration: |
_____________________________________ |
| Address: |
4817 Parker Drive, N. Charleston, SC 29405 |
| Phone: |
803-466-6076 |
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