Please enable JavaScript in your browser to complete this form.By signing this form, you agree that your credit card will be charged for the balance of the approved service that are rendered on the day of service. The patient/guardian/durable power of attorney/responsible party approves services verbally or written prior to services. You will receive a statement of services and credit card charge via email, fax, or mail. I authorize DIVA Mobile to charge my credit card an amount due for the services received. In case there are any problems with my credit card, I agree to provide alternative payment. If not, I agree to pay collection and attorney fee. Credit Card InformationCredit Card *VISAMastercardAmerican ExpressDiscoverCard Number: *LayoutExpiration Date (MM/DD) *Security Code (3 digit) *Name on the card *Initials (serving as electronic signature) *My Contact InformationLayoutNameRelationship to patient *Phone *FaxEmail *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePlease send me the statement via *EmailFaxAddressSubmit