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Credit Card Payment Consent Form

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Credit Card Payment Consent Form Powered By Docstoc
					                                Credit Card Payment Consent Form

Name:
______________________________________________________________________
First                   Middle Initial                Last


Name on card if different:

______________________________________________________________________
First                   Middle Initial                Last


I authorize Michelle Malloy, MFT to charge my credit card for professional services as follows:

Please read and initial:

__________ a. All dates of service beginning _____/_____/_____ .


__________ b. Recurring charge for dates of service at $___________ per visit.


__________ c. Missed appointments or appointments cancelled with less than 24 hours
              notice for the fee of $50.

__________ d. I understand that a $2.00 convenience fee - per transaction - will be
              added to the amount charged. This fee is utilized solely for purposes of
              maintaining this service


Type of card: ___ Visa       ___ MasterCard    Expiration date:_____/_____/_____


Card No.:_________________________________________Security code:__________

Card holder’s billing address for credit card statements:

______________________________________________________________________
Street                        City              State       Zip


Card holder’s signature:__________________________________ Date:___________

				
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