ACH / Credit Card Authorization Form Instructions
CONCEPTUAL MINDWORKS, INC. DBA SEVOCITY® / 13409 NW Military HWY, Suite 201 / San Antonio, TX 78231
P 877-777-2298 / P 210-737-0777 / F 210-737-6677 / E finance@sevocity.com
These items MUST be completed entirely in this order in order for the form to
generate the FINISH button.
- Complete Date field first – This should be the effective date to apply this payment
form. - Complete Sevocity Account Name – this should be the name of your Practice or
Clinic. - (Existing Customers Only) Complete Billing ID, i.e. SEVxxxx.
- Choose Account Type by clicking inside the appropriate button. A Type MUST be
chosen before payment fields will be active. - Inside the appropriate Payment Type box, a payment form (Checking or Savings,
VISA, MasterCard, AMEX) button MUST BE chosen to enter the data. - Complete information is required in each field.
- Enter complete information in all remaining fields to activate the FINISH button in
lower right hand corner. - Click on the FINISH button to send completed form to Sevocity Finance.