ASTS Credit Card Authorization Form

Credit card Authorization Form

In order for ADVANTAGE SPEECH THERAPY SERVICES, INC to accept and bill your credit card, please complete all fields below,sign, date and click on submit.

All information sent is strictly confidential and ADVANTAGE SPEECH THERAPY SERVICES, INC adheres to the highest standards of account data protection.

Billing Information: (as it appears on your credit card statement)

Company:

Customer name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

Confirmation EmailEmail must match to current email on file

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Amount*

Credit Card Authorization$0.50

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please check all boxes to express your complete understanding*

I understand that my card will appear to reflect the $0.50 charge initially but it will not charge my card as it will just save it on file in case of delinquent invoices.I understand that my credit card will be charged for delinquent invoices.I understand that my credit card will be charged the fee for missed appointments.I understand that my credit card will be charged the processing fees.

Please Check the First Box for Initial Set-up:*

One Time Use for reasons stated above: I hereby authorize ADVANTAGE SPEECH THERAPY SERVICES, INC to charge the indicated credit card the amount indicated above. This is a one-time charge authorization. I am not authorizing ADVANTAGE SPEECH THERAPY SERVICES, INC to setup my account within a recurring billing system. I understand that if I want ADVANTAGE SPEECH THERAPY SERVICES, INC to charge any balances to my credit card in the future, I will need to submit another authorization form at that time or choose the selection below.Recurring Billing: I hereby authorize ADVANTAGE SPEECH THERAPY SERVICES, INC to charge the indicated credit card on a monthly basis for the amount due for services provided with ADVANTAGE SPEECH THERAPY SERVICES, INC as indicated above. This Recurring Payment Authorization shall remain in force until cancelled by me in writing.

Signature*

Date*

Date