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II]
DORAL INN & SUITES
Third Party Credit Card Authorization Form
This form has been created in order to allow you to have third party expenses charged to your credit/debit card. I understand that the hotel is not
required to accept this form and the guest should check with the hotel to ensure they accept third part transactions. Please provide all the
information requested below to ensure prompt processing of your application. We ask you to please sign and date the form before submission.
Please fax the completed form to Doral Inn and Suites Miami Airport West at (305) 429 8754
FOR SECURITY reasons. Doral Inn and Suites conforms to all Payment Card Industry (PCI) standards. However, we recommend that the
credit card holder purchase a gift card for the guest (if possible) rather than send their credit card number via this third party form.
CARDHOLDER INFORMATION - Required
Name as it appears on the credit/debit card:
Card Type:
Account Type:
Issuing Bank:
Account Number:
Address (statement):
City, State, Zip:
Phone Number.
JER-ciac-s•I G €-,-ps-rel,.1
El Visa
El MC
laikmex
Diners/CB
Discover
Fax or Alternate Numbe
GUEST INFORMATION -
Guest Name:
Address:
City, State, Zip:
Company:
Phone Number:
Confirmation Number:
- 0 Debit / 0 Credit
C-;i24CA
Corporate - Company Name:
Phone:
Exp. Date: gal
JCS
Relation to Cardholder:
Relative
Fax or Alternate Number:
Arrival Date: TAr.1 3, a5::)11
Departure Date: Tpvti .
apt&
agend
Business Associate
Other
understand that should there be any issues with the credit/debit card being used to settle my charges. I will be responsible for all expenses incurred
during my stay. Departure date cannot be extended unless a new authorization form is completed.
Guest Name: (Printed)
Guest Signature:
RATE INFORMATION AND APPROVED CHARGES - Required
Room Rate:*
tc,S) , as Taxes:*
Total Daily Rate:*
*(Rate and tax amount must be provided by a hotel representative in order to complete this form.)
ErAll Charges
Room & Tax
K Telephone (LD)
Telephone (Local)
Room Service
Other
Date:
Valet/Laundry
Parking
El HS Internet Access
Number of Nights:
ID Restaurant
Movies
I certify that all information is complete and accurate. I hereby authorize Doral Inn and Suites Miami Airport West to collect payment for all charges
as indicated in the Rate Information and Approved Charges section of this form by processing a charge to the credit/debit card listed above. Charges
must not exceed $5,000 for the entire stay/event. I understand that a new form will have to be completed if guest wishes to extend his/her stay. I
certify that I am the authorized signer of the credit/debit card listed above.
Cardholder Name: (Printed)
Cardholder Signature:
r
Date: SSAdaaae_
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GPSTFirJ
Please do no s nd a photocopy of the front or back of your credit card.
1212 NW 82" Avenue. Miami FL 331261 P : (305) 629 8755 / FAX (305) 629 8754 / MAW docalmnandsuites.com /email: cloralinneolsolesegmailcan
EFTA00313800
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EFTA00313801
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EFTA00313802
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EFTA00313803
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well Cornell Medicine
Center for Comprehensive
Spine Care
Attn: Jude Anthony A Garcia
Please note which department or physician you are requesting to see:
Phone: (888) 922-2257 (888-WC-BACKS)
Please return this form to our office via fax. (646)962-0640
n 'For Eric Bowl% MD; Kai-Ming Fu, MD; and
All A. Baal, MD; please return forms to (646) 962-0119
1‘11
• k ART L_
Neurosurgery
Neurology
Pain Management
NEW PATIENT QUESTIONNAIRE
Patient Name:
C--
re171
Date of Birth: Cl /
/ I 9 53 Gender: M
Phone Number:
ddress:
GAS? —413r sr, N Y it! local
Referred by h
Insurance Carrier/ ID or Policy Il i 4t1 I -Tr> ii•EAL;THCA
Reason for Visit:
Have you had a history of accident or injury? If yes, please explain and answer the next three questions:
1. LA h t
•
Was the accident at work? Yes or No
•
Are you using Workman's Compensation? Yes or No
•
Are you currently involved in litigation? Yes or No
On the diagram below, please mark where you are
feeling your symptoms with the appropriate letters.
RIGHT
LEFT
LEFT