On-File Credit Card Form Request

On-File Credit Card Form Request

For Current Client Use Only
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
MM-DD-YYYY
Responsible Party Name (Parent or Legal Guardian if client is under age 18)*

First NameLast Name
Email Address where you'd like to receive the secure Credit Card form
example@example.com
After completing this form, a member of our team will email you a secure document to fill in your card details, so watch for that email to come through, and please complete asap. Once finalized, this info will be stored in our secure credit card system and will only be accessed to charge the patient-responsibility portion of your services after each kept appointment. Email info@aspenridgecounselingcenter.com with any questions.
Should be Empty: