Credit Card Authorization

Credit Card Authorization

Venus Wellness Center, LLC
I authorize and give permission to Venus Wellness Center, LLC to keep my signature on file and charge my Visa, Mastercard, American Express, Discover, or other prefered payment card/method for all psychotherapy related charges associated with my account. My card details will be stored in my profile, and charged on the next business day.
The following payment options are in place to keep your credit card information secure. ***Please note that credit card information must be collected prior to your scheduled session.
Preferred Contact Information
Patient Name

First NameLast Name
Cardholder Name (if different from the Patient)

First NameLast Name
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cardholder Signature
Thank you,

Veronica Pianoforte, PhD, LCSW

Venus Wellness Center, LLC
Should be Empty: