By entering your credit card information, you authorize Transaction Express to debit the bank account or credit card indicated in this web form on behalf of Coastal Medical, Inc. You understand that because this is an electronic transaction, these funds may be withdrawn from your account as soon as the transaction date.

You certify that you are an authorized user of this credit card or bank account, and that you will not dispute the payment with your Credit Card Company or Bank, so long as the transaction corresponds to the terms indicated in this web form.