• Credit Card Payment Authorization Form

    Sign and complete this form to authorize The Center for Treatment of Anxiety Disorders to make a debit to your credit card listed below. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date.
  • Please complete the information below:
  • I authorize The Center for Treatment of Anxiety and Mood Disorders to chard my credit card for the below amount on or after the below date on this form.

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  • I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

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