Card Type *

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.

Billing Date *

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.