Mindy Stein, P.A. Credit Card Charge Form

Please fill out form below and click submit

Type of Card:
Invoice#(if applicable):
Credit Card Number:
Expiration Date:
Security Code:
Name on card:
E-mail address:
Amount:

To submit your form, press this button:

To clear the form, press this button:

Please Note: Our firm does not charge credit card fees for credit card charges. However, if we issue a refund or partial refund to a client, we deduct the credit card fee from the refunded amount. The Fee is currently 3%.

Thank you for your business