cc Auth Form

Physician/Clinic Profile

First Name *

Last Name *

Clinic/Practice Name *

Address *

Address Line 2

City *

State *

Postal code *

Country *

Country

Email *

NPI Number

Credit Card Authorization

Please provide a valid credit card below for us to keep on file to pay invoices. All invoices are due on receipt and auto-billed when issued.

Card Number *

Card Expiry *

CVC *

Billing Address

Street Address *

Address Line 2

City *

State *

Postal / Zip Code *

Country *

By signing below, I authorize Celia Health to keep my signature and credit card information on-file in my account and charge my credit card for outstanding balances when due. This authorization will remain in effect until revoked by me in writing to Celia Health.

Signature *

Please sign to complete your authorization.

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