Credit Cart Authorization Form

PATIENT’S NAME :

PATIENT’S EMAIL :

NAME OF CARDHOLDER (How it appears on the card) :

BILLING ADDRESS :

CITY :

STATE :

ZIP CODE :

VISAMASTERCARDAMEXDISCOVER

CREDIT CARD NUMBER :

EXP DATE :

CVV NUMBER (3-digit number on the back of the card) :

I hereby authorize Leslie Zebel PhD, Psychotherapist to charge the above credit card for the patient name listed above. I certify I have full authority to make purchases on behalf of the account listed above. Please note in the event that you fail to come to your scheduled appointment, or do not provide at least 24 hour notice of your cancellation, your card will be charged a cancellation fee, as indicated by the Informed Consent policies.

SIGNATURE OF CARD HOLDER :

DATE :

PRINTED NAME :