Credit Cart Authorization Form

Leslie A. Zebel PhD, Psychotherapist
Licensed Mental Health Counselor #4375
Certified Addictions Professional
7401 South Olive Avenue
West Palm Beach, FL. 33405
561-585-8787
Drlesliezebel.com
lzebel@aol.com

VISAMASTERCARDAMEXDISCOVER

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.