Quick Doc Coder Credit Card Fax Form

  • Complete the following information.
  • Complete one order for each Practice Partner(TM) licensed practice
  • Print and Sign at bottom, then Fax to 717-845-5181.

Office Information
Office Name      
Phone
Fax
E-mail

Credit Card Information
Card Type
Credit Card #
Exp. Date
Card Owner
Address
Address Line 2  
City
State
Zip
Country

Price
Practice Size
Sales Tax
Total              $ 
                       
Comments
   
I agree to have the above sale and any applicable taxes charged to this credit card.
Authorized Signature