Credit/Debit Card Authorization Form

1
Client Name* This field is required.Recipient of Acorn & Oak Services
First Name
Last Name
2
As the cardholder and person responsible for recurring session copays or session fees, hereby authorize Acorn & Oak LLC to charge my credit card for session copays or session fees at the time of service or anytime thereafter if there is a balance due.

I confirm that the information for the credit card and billing address is complete and accurate, and I will update this information if anything changes.

I have been informed that I can cancel the recurring payment at least 14 days before the payment by emailing Acorn & Oak at officeadmin@acornoakmaine.com.
3
Credit/Debit Card Information* This field is required.
CARDHOLDER NAME
CARD NUMBER
EXPIRATION DATE
CVV
BILLING ADDRESS (MUST INCLUDE ZIP CODE)
4
Cardholder Signature* This field is required.
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