📋 Patient Intake Book Now 📞 (301) 806-0361

New & Returning Patients

Card-on-File Authorization

Authorize AmeriDrip to keep your card on file in Square for agreed-upon purchases. Complete and electronically sign the form below.

Cardholder Information
Authorization
I authorize AmeriDrip to charge the credit card identified above for agreed-upon purchases. I understand my card information will be saved in Square for future transactions on my account. I may cancel this authorization at any time by contacting AmeriDrip at (301) 806-0361 or itamar@ameridrip.com. This authorization remains in effect until canceled.

This form records your permission. It does not save or charge your card. Provide your full card details directly through Square or with AmeriDrip staff. Do not enter your full card number or security code here.

📞 Call Now Book Now