Credit Card Authorization Form

The required deposit will be applied towards the total cost of your services, ensuring that your appointment is reserved exclusively for you.

Procedure Date *

Please note, while we strive to accommodate your preferred procedure date, it cannot be guaranteed. We recommend selecting a date at least one week from now for better availability

Patient Driver License

Patient Signature *

Clear

Cardholder Information

Relationship to Patient *

I hereby authorize CG Cosmetic Surgery to process a charge on my credit card and/or withdraw funds from the specified account. This transaction will be applied towards my outstanding balance. I understand and acknowledge that my deposit of $1,000.00 is NON-REFUNDABLE. I am also aware that it is mandatory to present the credit card used for this transaction on the day of my services. Failure to do so grants the Accounting Department the authority to CANCEL my scheduled services.

Authorization *

I agree to the terms and authorize the transaction

Cardholder Signature *

Clear

Cardholder Driver's License *

By providing my phone number, I agree to receive text messages from CG Cosmetic. By submitting, I consent to receiving occasional notifications and promotional messages by text and email. You can opt-out by replying "STOP". I also acknowledge that I have read and agree to the Terms & Conditions. Please read our Privacy Policy here.

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