|
Dear
Dr. _______________________,
This
states you were referred to me by one of the above circled 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
803-732-5578 for Credit Card Payment
or mail to: TopSurgeonsOnline, 1557 Wonder Drive, Chapin, SC 29036
Check available upon request.
Payment Info to be Faxed back to Surgeon's Office
| Name on Card: |
_____________________________________ |
| Visa #: |
_____________________________________ |
| Expiration: |
_____________________________________ |
| Address: |
1557 Wonder Drive, Chapin, SC 29036 |
| Phone: |
803-732-5578 |
|