Credit Card Information for Health Care

While a student at the American Hebrew Academy your son/daughter may need medical care or pharmacy services.  In order to pay the practitioners, pharmacy, co-pay, or other charge at the time of service, we will need a credit card number, expiration date and VIN (security) number, as well as your signature. 

This form will be kept in a locked file and used only for necessary medical fees as mentioned above.  A copy of every receipt will be sent to you as soon as possible after it is charged. 

Please complete the form below and return it with the other health forms by

July 15, 2018 and please be sure to let us know if your card has become compromised/ or changed by calling  (336) 217-7080 or by email to HealthCenter@aha-net.org.

While a student at the American Hebrew Academy your son/daughter may need medical care or pharmacy services.  In order to pay the practitioners, pharmacy, co-pay, or other charge at the time of service, we will need a credit card number, expiration date and VIN (security) number, as well as your signature. 

This form will be kept in a locked file and used only for necessary medical fees as mentioned above.  A copy of every receipt will be sent to you as soon as possible after it is charged. 

Please complete the form below and return it with the other health forms by

July 15, 2018 and please be sure to let us know if your card has become compromised/ or changed by calling  (336) 217-7080 or by email to HealthCenter@aha-net.org.