CC Authorization - Center for Anxiety

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Patient Name:*
First Last
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Parent/Legal Guardian First Name
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Parent/Legal Guardian First Name
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I am this patient's parent/legal guardian
- I am this patient's parent/legal guardian
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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.
Card Type*
- MasterCard
- VISA
- Discover
- Amex
Cardholder Name (as on card):*
Card Number:*
Expiration Date (mm/yy):*
MM slash DD slash YYYY
Card holder ZIP Code (credit card billing address):
I
authorize Center for Anxiety LLC/NewYork City Psychology, PC. to charge my credit card above for agreed upon purchases.

I understand that my information will be saved to file for future transactions on my account.
Date:*
MM slash DD slash YYYY
Email*
Signature:*

Credit Card Authorization Form