Credit Card Authorization Form

I authorize Dr. Pedraza and Bio Behavioral Therapeutics to make recurrent payments for the services provided to me or my child.
Patient's Name
Card Holder's name:
Address:
Signature of Card Holder:

Clear
Date:

MonthDayYear
Date
You will receive an invitation to join an online portal so that you can make payments. The information will be saved in an encrypted server once you have entered your credit card information.
Email
example@example.com
Should be Empty: