PAYMENT AUTHORIZATION FORM

PAYMENT AUTHORIZATION FORM

Your payment information is protected through our secure system and will only be used for authorized transactions related to your care. We prioritize your privacy and security.
Client Name:*

First NameLast Name
Would you like us to delete the card that is currently on file?

YesNoNot Applicable
If you answered 'yes' to the above question, what are the last 4 digits of the card you'd like us to delete?
Name on Card (if different than above):

First NameLast Name
Card Number: *
Expiration Date (month / year):*
Security Code (on back of card):*
Billing Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Comments / Notes for Billing Department:
I acknowledge and agree that Open Space Counseling, Consulting & Wellness may charge my payment method on file for any outstanding balances, including late cancellation and no-show fees, without requiring additional authorization.
Cardholder Signature

Clear
Should be Empty: