Credit Card Acknowledgement

Credit Card Acknowledgement
Client name*

First NameLast Name
Client Date of birth*

MonthDayYear
Date
Age
Your relationship to the client*
Your name*
Phone number*
Please enter a valid phone number.
Email*
example@example.com
Last 4 digits of the credit card*
Type of Card
If your primary card is an HSA, we’ll also need a backup card on file. To set this up, just fill out an additional Credit Card Acknowledgement form for your backup card and give our office a quick call to add it.

If you happen to know the date your HSA usually reloads, please share that with us too—it helps us time things smoothly.
If you have not already done so, please call our front office at (586) 580-2975 to provide your full card number. Due to PHI compliance, we are unable to collect full numbers on this form.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: