Credit Card Authorization Form

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by notifying us in writing. This authorization will remain in effect until cancelled.
Card Type

VisaMaster CardDiscoverAmex
Card Holder's Name

First NameLast Name
Card Number
Expiration Date

MonthDayYear
Date
Security Code
Billing Zip Code
Email Address for Invoices
example@example.com
I authorize Parker Speech and Language Therapy to charge my credit card for all speech therapy services. I understand that my information will be
securely saved to file for future transactions on my account. I understand that I will receive a receipt for all transactions.
Print Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: