{"id":14118,"date":"2024-12-11T20:07:34","date_gmt":"2024-12-11T20:07:34","guid":{"rendered":"https:\/\/dermacarebrickell.com\/?page_id=14118"},"modified":"2026-04-20T16:47:42","modified_gmt":"2026-04-20T16:47:42","slug":"credit-card-authorization-form","status":"publish","type":"page","link":"https:\/\/dermacarebrickell.com\/?page_id=14118","title":{"rendered":"Credit Card Authorization Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"14118\" class=\"elementor elementor-14118\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2aa4f32 elementor-section-boxed elementor-section-height-default elementor-section-height-default qodef-elementor-content-no\" data-id=\"2aa4f32\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-6d7974c\" data-id=\"6d7974c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5ca20be elementor-widget elementor-widget-heading\" data-id=\"5ca20be\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Spring Beauty Bash CC Authorization<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c0944fa elementor-section-boxed elementor-section-height-default elementor-section-height-default qodef-elementor-content-no\" data-id=\"c0944fa\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-16cbc6d\" data-id=\"16cbc6d\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6e0fd52 elementor-widget elementor-widget-text-editor\" data-id=\"6e0fd52\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><em><strong>This form is for purchases of $1000 or more ONLY.<\/strong><\/em><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6601d89 elementor-section-boxed elementor-section-height-default elementor-section-height-default qodef-elementor-content-no\" data-id=\"6601d89\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-9faf069\" data-id=\"9faf069\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-36f9aa3 elementor-widget elementor-widget-shortcode\" data-id=\"36f9aa3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f14117-o1\" lang=\"en\" dir=\"ltr\" data-wpcf7-id=\"14117\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F14118#wpcf7-f14117-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"14117\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f14117-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"full-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Full Name\" value=\"\" type=\"text\" name=\"full-name\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address\" value=\"\" type=\"email\" name=\"email\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone Number\" value=\"\" type=\"tel\" name=\"phone\" \/><\/span>\n<\/p>\n<p><label> Name as it appears on the card (required): <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"card-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name as it appears on the card\" value=\"\" type=\"text\" name=\"card-name\" \/><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"credit-card-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Credit Card Number\" value=\"\" type=\"text\" name=\"credit-card-number\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"expiry-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Expiration Date (MM\/YY)\" value=\"\" type=\"text\" name=\"expiry-date\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cvv\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"CVV\" value=\"\" type=\"text\" name=\"cvv\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"amount\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Amount (e.g., 100.00)\" value=\"\" type=\"text\" name=\"amount\" \/><\/span>\n<\/p>\n<p><label> Card Type (required): <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"card-type\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"card-type[]\" value=\"Visa\" \/><span class=\"wpcf7-list-item-label\">Visa<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"card-type[]\" value=\"MasterCard\" \/><span class=\"wpcf7-list-item-label\">MasterCard<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"card-type[]\" value=\"Amex\" \/><span class=\"wpcf7-list-item-label\">Amex<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"card-type[]\" value=\"Discover\" \/><span class=\"wpcf7-list-item-label\">Discover<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"card-type[]\" value=\"Care Credit\" \/><span class=\"wpcf7-list-item-label\">Care Credit<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><strong>Billing Address:<\/strong>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"billing-address-line1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address Line 1\" value=\"\" type=\"text\" name=\"billing-address-line1\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-address-line2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address Line 2 (Optional)\" value=\"\" type=\"text\" name=\"billing-address-line2\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"billing-city\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"State\/Province\" value=\"\" type=\"text\" name=\"billing-state\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"billing-zip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"ZIP\/Postal Code\" value=\"\" type=\"text\" name=\"billing-zip\" \/><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Order details:\" name=\"details\"><\/textarea><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-12\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"How did you hear about us?\" value=\"\" type=\"text\" name=\"text-12\" \/><\/span>\n<\/p>\n<p><br \/>\n<strong>Disclaimer: By submitting this form, you acknowledge that you are authorizing Dermacare Brickell MD to charge your credit card. This form will be processed securely, and your information will be handled in compliance with applicable laws and regulations. Please ensure all information provided is accurate and complete. If you have any concerns, please contact us directly at (305) 579-9836 before submitting this form.<br \/>\n<\/strong>\n<\/p>\n<p><button class=\"wpcf7-form-control wpcf7-submit qodef-button qodef-size--normal qodef-type--filled qodef-m\" type=\"submit\"><span class=\"qodef-m-text\">Submit Authorization<\/span><\/button>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Spring Beauty Bash CC Authorization This form is for purchases of $1000 or more ONLY.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-14118","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/dermacarebrickell.com\/index.php?rest_route=\/wp\/v2\/pages\/14118","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dermacarebrickell.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dermacarebrickell.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dermacarebrickell.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dermacarebrickell.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=14118"}],"version-history":[{"count":25,"href":"https:\/\/dermacarebrickell.com\/index.php?rest_route=\/wp\/v2\/pages\/14118\/revisions"}],"predecessor-version":[{"id":14647,"href":"https:\/\/dermacarebrickell.com\/index.php?rest_route=\/wp\/v2\/pages\/14118\/revisions\/14647"}],"wp:attachment":[{"href":"https:\/\/dermacarebrickell.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=14118"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}