Credit/Debit Form

Credit / Debit Card Payment Consent Form

Client Name: *

Name on Card if different than client:

Card Number: *

Expiration Date: *

CVC: *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

I authorize Suffolk Family Therapy LCSW P.C. to charge my credit/debit/health account card for professional services. If I do not cancel before 24 hours, I recognize that Suffolk Family Therapy LCSW, P.C. will charge my card as a late cancel or no show if I do not show up for the appointment. I will be billed for my full session fee for late cancel or no show fees. I verify that my credit card information, provided above, is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied. I also understand by signing and initialing this form that if no payment has been made by me, my balance will go to collections if another alternative payment is not made within thirty days. *

Initial Here

Signature *

Date / Time *

Date

Time