Credit Card Authorization Form

Credit Card Payment Consent Form
Print Last*
First*
Middle Initial
Name on Card if different
| authorize David A. Yudell, Psy.D., and Card One International, to charge my credit/debit card for professional services as follows:
Recurring charges per visit in the amount of
One time charge in the amount of
Type a question
3-digit number in reverse italics on the back of the credit card OR 4-digit on front of Amex cards

Card Holder's Billing Address for Credit Card Statements
Street*
City
State
Zip*
Type of Card

Type option 1Type option 2Type option 3Type option 4
Initial
Signature*

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