Receipt
2300 W Plano Pkwy Plano, TX 75075 (972) 577-0000
Date : Sep 12 2016
Type : Credit Card - Sale
First Name : Sara
Last Name : Taylor
Patient ID : 21645
Type : Credit Card - Sale
First Name : Sara
Last Name : Taylor
Patient ID : 21645
Authorization Amount : $450.00
Authorization Code : 9D8079
Card Holder Name : Sara Taylor
Card Type : VISA
Card Number : ************1111
Response Message Code : APPROVAL 000
Mode : Issuer
I AGREE TO PAY THE ABOVE AMOUNT ACCORDING TO MY CARD HOLDER AGREEMENT