Credit Card Authorization

Credit Card Authorization
In my absence, as the financially responsible payee for therapy services for
Client's Name*
I authorize Boundless Hope LLC to charge my credit card on file. This transaction will occur whether services are rendered or if an appointment is late canceled as delineated in the informed consent. I can receive a receipt directly from the credit card merchant after services are billed.
My preference in the receipt be sent via text/email to*
example@example.com
Authorized Signature*

Clear
Authorized Printed Name*
Date*

MonthDayYear
Date
Should be Empty: