Payment Options

Payment Authorization Form

Student's Name *

First Name

Last Name

Credit Card Information

Name on Card *

First Name

Last Name

Billing Address *

Address Line 1

Address Line 2

City

State

Zip

Card Info *

Credit Card Number

Expiration Date

CVV Number

Email Address that you would like the receipt sent to? *

Which Course is the student taking?

Which Course is the student taking?

Payment Options *

Intro to Orthodontics - Payment Options

I authorize the Ocean Point to charge my credit card for the authorized amount below today. *

Yes No