MEDICAL INVOICE
Bill From Bill To Invoice No. ___________
Name: ____________ Name: ________________
Company Name: ______________ Company Name: ______________ Invoice Date: ________
Street Address: _______________ Street Address: _______________
City, ST ZIP Code: ______________ City, ST ZIP Code: ______________ Due Date: ________
Phone: ________________ Phone: ________________
Medical Services Performed Medication Patient Rate ($) Total ($)
Subtotal
Sales Tax
Other
Total
Terms and Conditions
Thank you for your business. Please send payment within ______ days of receiving this invoice. There
will be a ______% per ______ on late invoices.
Page 1 of 2
Please Choose a Payment Type
Credit Card
☐ Visa ☐ MasterCard ☐ Discover ☐ American Express
Cardholder Name ___________________________
Account/CC Number ___________________________
Expiration Date ____ /____
CVV ____
Zip Code _______
I authorize the above named business/individual to charge the credit card indicated in
this authorization form according to the terms outlined above. This payment
authorization is for the goods/services described above, for the amount indicated above
only, and is valid for one (1) time use only. I certify that I am an authorized user of this
credit card and that I will not dispute the payment with my credit card company; so long
as the transaction corresponds to the terms indicated in this form.
SIGNATURE ___________________________ DATE _____________________
(cardholder name)
Bank Wire
Name on Bank Account: _________________________
Street Address: _________________________
Bank Name: _________________________
Account Number: _________________________
Routing Number: _________________________
Account Type: _________________________
Email: __________________________
Page 2 of 2
