Epstein Secrets

If you would like to pay by credit card or Type of card (check one) automatically debit your bank aocount on an K Visa 7 Discover MasterCard " American Express ongoing basis, please call Customer Care at Account Number 1-800-639-6111 or dial 611 from your Nextel phone, for additional information. Credt

Name (as it appears on the carte If you would like to pay by credit card or Type of card (check one) automatically debit your bank aocount on an K Visa 7 Discover MasterCard " American Express ongoing basis, please call Customer Care at Account Number 1-800-639-6111 or dial 611 from your Nexte

If you would like to pay by credit card or Type of card (check one) automatically debit your bank aocount on an K Visa 7 Discover MasterCard " American Express ongoing basis, please call Customer Care at Account Number 1-800-639-6111 or dial 611 from your Nextel phone, for additional information. Credt

ent Name ou appears on the carta If you would like to pay by credit card or Type of card (check one) automatically debit your bank aocount on an K Visa 7 Discover MasterCard " American Express ongoing basis, please call Customer Care at Account Number 1-800-639-6111 or dial 611 from your Nexte

10021 Payer E-Mail Relationship to Patient friend Payment Amount Indicate type of credit card to be charged (We do not accept Debit Cards) IRl American Express K Mastercard K Visa K Diners Club K Discover Credit Card Number Exp. Date CVN Cardholder's Information: Me Address where the credit card s

ip to Patient friend Payment Amount Indicate type of credit card to be charged (We do not accept Debit Cards) IRl American Express K Mastercard K Visa K Diners Club K Discover Credit Card Number Exp. Date CVN Cardholder's Information: Me Address where the credit card statements are mailed)

Zip Code 10021 Payer Relationship to Patient friend Payment Amount Indicate type of credit card to be charged (We do not accept Debit Cards) Z American Express K Mastercard K Visa K Diners Club K Discover Credit Card Number Exp. Date 05/16 CVN 9129 'Cardholder's Information: (The Address where the

ship to Patient friend Payment Amount Indicate type of credit card to be charged (We do not accept Debit Cards) Z American Express K Mastercard K Visa K Diners Club K Discover Credit Card Number Exp. Date 05/16 CVN 9129 'Cardholder's Information: (The Address where the credit card statements