Credit Card Authorization Form

Kindly submit this form to authorize a charge of $150.00 to your card listed below, in the event of no-show or cancellation less than 48 hours prior to your appointment. Please note your card will be charged and refunded $1 upon receipt of this form for verification purposes, subsequent to which you will receive a confirmation of your appointment. Thank you for your cooperation.

Dr. Horri Aesthetic Reconstructive Dentistry

45 Rockefeller Plaza, Suite 1857

New York, NY 10111

(212)586-0410

info@maryamhorri-dmd.com