Account Authorization – YDL Dental Portal

YDL Dental Laboratory- Credit Card ACH Authorization Form

Name*

First Last

Practice Name*

Email*

Phone*

Credit Card Information

Card Type*

Visa

MasterCard

American Express

Discover

Credit Card Number*

Expiration Date*

Name on Card*

Verification Code*

Signature*

By typing in your legal name, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

Date*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Date*

Weekly (Every Thursday)

Monthly on the 1st

Monthly on the 15th

Monthly on the 30/31st

Terms and Conditions*

I hereby authorize YDL Dental Laboratory to retain my signature on file for the purpose of charging the
credit card listed above for the monthly balance of my statement. I will receive my monthly statement in
electronic format, for my records.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify
YDL Dental Laboratory of any changes in my card information or termination of this authorization at
least 15 days prior to the billing date selected above.

I agree not to dispute this recurring billing with my credit card so long as the transactions correspond to
the billing statements.

Client agrees to pay any collection costs incurred in the collection of any delinquent account including reasonable attorney fees.
Once an account becomes delinquent, the card on file will be processed for the past due amount.

I agree to the terms and conditions.