CREDIT CARDHOLDER'S AUTHORIZATION

In lieu of my credit card imprint, I________________________________________
                                                  (Name of Cardholder as shown on Credit Card)

Hereby authorize_____________________________________________________
(USMDDirect)

To charge my________________________________________________________
               (Credit Card Name)        (Credit Card Number)           (Expiration)

                          In the amount of $__________for payment of services___________________________                   

       Note: Identification is required. Please provide Photostat of Credit Card (Front & Back)
and Passport or Driver's License of Cardholder or Nation Identification Card.         
      
          By signing below, I acknowledge charges described hereon, Payment in full to be made
     when billed or in extended payments in accordance with standard policy of company
                                  issuing card.                                                                                                                                   
        
   (SAME AS ABOVE)                                                                                          
                                                                                   
        ________________________                                                                                     
Signature of Cardholder                                                                                      

                                                                                
  _______________________                                                                               
    Print Name                                                                                                        

     PLEASE FAX THIS FORM TO:                                                                               
            USMDDIRECT.COM                                                                                                     
    ATTN: ACCOUNTING                                                                                           
  FAX NO.(310) 449-1415                                                                                      

AND ALSO MAIL ORIGINAL TO:                                                                      
USMDDIRECT.COM                                                                                         
   1301 20th street Suite290                                                            
   SANTA MONICA, CA 90404