I-MEDSOURCE PATIENT FAX COVER SHEET
FAX T0 1-888-337-0636
Customer Service Number: 1-800-471-6485 ext. 81
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CREDIT CARD AUTHORIZATION FORM
Please Include All Documents Listed Below To Expedite Your Consultation
| Valid state or government issued photo ID of cardholder and patient | |
| Front and back of Credit Card. |
This information is being collected for the sole purpose of preventing unauthorzied credit card transactions.
We make sure that every online communication with our customers meets our high standards of privacy and security. We do this by using a secure server with software that encrypts all of your confidential information. In addition, we take a range of measures to protect all customer data against unlawful or unauthorized access and have in place appropriate physical, technical and organizational security procedures to protect against damage, loss, destruction, misuse and alteration of customer data.
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