CC Authorization - Center for Anxiety

Hidden
Patient Name:*
First Last
Hidden
Parent/Legal Guardian First Name
Hidden
Parent/Legal Guardian First Name
Hidden
I am this patient's parent/legal guardian
- I am this patient's parent/legal guardian
Hidden
Date of Birth:
MM slash DD slash YYYY
Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.
Patient Name:*
Card Type*
- MasterCard
- VISA
- Discover
- Amex
Cardholder Name (as on card):*
Card Number:*
Expiration Date (mm/yy):*
MM slash DD slash YYYY
CVV*
Billing Street Address:*
Billing Zip Code:*
By signing the below I, the cardholder, authorize Center for Anxiety LLC/NewYork City Psychology, PC. agree to pay, and specifically authorize the charge of my credit card for the services provided. I understand that my information will be saved to file for future transactions on my account. I further agree that in the event my credit card becomes invalid, I will provide a new valid credit card upon request, to be charged for the payment of any outstanding balances owed.
Date:*
MM slash DD slash YYYY
Email*
Signature:*

Credit Card Authorization Form