FORMS

If instructed by the PVMED office, print, fill out, sign, and return the top half of the the credit card agreement form.  This form, when signed, authorizes PVMED to bill multiple transactions to your credit card. Return this form to the PVMED Office.

For security purposes, we do not permit this form to be filled out online or in a web browser.
A signed paper copy must be on file with the PVMED office.