I give permission to Tangerine Physical Therapy, Inc. to use my credit card information in order to process payments for Occupational or Physical Therapy services. This credit card will also be used for late cancellation fees, no show fees and additional balances.

I, {cardholderName}, as a cardholder, hereby authorize Tangerine Physical Therapy, Inc. to charge my credit card for balances accrued on my childs account with the information saved and confirm that the information for the credit card and billing address is complete and accurate.