n Officer Borrower Name Name on Credit Card Credit Card Type Credit Card Number Expiration Date Amount to be charged Loan Number Joann Brown K Mastercard K Visa Borrower's Authorization Signature R eqter ed Authorization D ate Relationship to Borrower CONFIDENTIAL SIDNY_GM_00030283 EFTA_00140901

Referring Name Accession 10/14/20157:30 AM EDT MRLSPNI MOSKOWITZ, BRUCE W, M.D 6784742 PAYMENT IS DUE AT THE TIME OF SERVICE K Cash K Check K Mastercard K Visa K Amex K Discover I HEREBY ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR ANY UNPAID BALANCES. Signature of Patient or Guardian: £LLbh£LZLZ

dress: City, State and Zip: Cardholder Information Name as it appears on the credit card: Type of Card: Account Type: Account Number: K Visa K Mastercard K American Express K Discover K Individual (Personal Credit Card) K Corporate Company Name: Address (Billing Address): City, State and Zip:

, c, c r ei Please Keep My Form on File For Future Use ET Cardholder Infarosalion Name as it appears on the credit card: Type of Card: K Visa K Mastercard Account Type: 2 Individual (Personal Credit Card) K Corporate Company Name: Credit Card Number: ■ Address (Billing Address): City, State and

ayer 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 credit card st

il 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 statements are