Bank Card Data Collection Form - Health Guard Hungary®

Bank Card Data

We securely collect your Bank Card Data (Credit or Debit Cards) in order to charge for our Services.

POS MOTO via OTP Bank will be used, meaning we charge the given Bank Card by using the data we collected without the physical presence of the card.

We may use Dynamic Currency Conversion (DCC) if available.

When you proceed with the Submission, you confirm that you read and agree to the content of the Service Provider’s website, including but not limited to Prices and Fees, General Information and Policy as well as the Privacy Policy. You particularly agree that no refunds may be given for cancelled services or in cases when You were not available for the requested and scheduled visits or services, according to the Terms and Conditions.

Bank Card Payment Data

Bank Card Holder’s Family Name

Bank Card Holder’s Given Name

Upload a Copy of the Data Page of the Bank Card Holder’s Passport or both sides of any other types Photo Identification Cards! The Document must contain the Photo of the Person’s face.

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Bank Card Holder and the Patient is the Same Person?

Yes

Patient’s Family Name

Patient’s Given Name

Patient’s Date of Birth, Year.Month.Day

The Amount of Payment you Authorize us to charge in HUF (Hungarian Forints). We may use Dynamic Currency Conversion (DCC) if available.

The Services you are Paying for (Use Reference Number if given)

The Type of Bank Card

Visa

Mastercard

American Express

Other

Other Type of Bank Card Used

Bank Card Number (Visa, MC, Other)

Bank Card Number (AMEX)

Confirm the Last 4 digits of the Bank Card used

Bank Card Expiration – Month / Year

Bank Card Security Code – 3 digits on back of card

Confirm the Last 5 digits of the AMEX Card used

Bank Card Expiration – Month / Year

Bank Card Security Code – 4 digits on front of card

Bank Card Security Code – 3 digits on back of card

Email Address of Payer

Confirm the Email Address of Payer

Email Address of Patient

Mobile Phone number of Payer with Country Code

Local Phone/Mobile Number of Payer

Mobile Phone number of Patient with Country Code

Local Phone/Mobile Number of Patient

Other Important Information you would like us to know. Optional field.

Additional File Upload – Optional

Choose File (pdf, jpeg, jpg, png, bmp, gif)

I have read and agree to the content of the Service Provider’s website, including but not limited to Prices and Fees, General Information and Policy as well as the Privacy Policy. I particularly agree that no refunds may be given for cancelled services or in cases when I was not available for the requested and scheduled visits or services, according to the Terms and Conditions.

Signature – Type your full name here as the first step to confirm your Identity. IMPORTANT! After you Submit the Form here you have to open the message sent to your Email and Click on the “Confirm Submission” Button.