Sign and complete this form to authorize DiStefano Hair Restoration to make a one-time charge to your credit card.

By signing this form, you give us permission to debit your account for the deposit amount indicted below. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

I acknowledge that this deposit reserves my surgical spot at DiStefano Hair Restoration Center and is non-refundable if I chose to cancel within 21 days of my procedure.

Deposit Amount: $2,500