authorize the office and staff of
Dr. Nilo A. Hernandez & Smilecreator of Naples LLC., to maintain on record and charge
my credit card for any and all current and past due charges / balances on my account or
any account for which I am responsible for.
These charges may include any unpaid claims or balances, cancellations within the
allowed time frames to which I have agreed, and any deposits for setting and securing
time slots for advanced times for depositions and conferences. I also understand that
every effort will be made on the part of the office staff to minimize any charges for the
successful development of the case.
The office staff will send a copy of any credit card transaction records to my address on
file for my record and that I will be given an explanation either by letter or telephone call.
I fully understand my obligations and agree to all of the terms listed above and am in a
sound condition to agree with them.