Credit Card Authorization Form - Lighthouse Psychological Services

CREDIT CARD AUTHORIZATION FORM

PLEASE PRINT ALL INFORMATION LEGIBLY & COMPLETELY.

All charges will appear on your credit card statement as “Lighthouse Psych Srvs.”

DATE: THERAPIST:

CLIENT NAME:

CARDHOLDER NAME:

(EXACTLY AS APPEARS ON CREDIT CARD)

CARDHOLDER ADDRESS:

PHONE:

EMAIL:

CREDIT CARD TYPE (Check one):

VISA

MASTERCARD

CARD NUMBER: ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

EXPIRATION DATE: _____

________

VCODE:

Month

Year

AMOUNT TO CHARGE:

I authorize Lighthouse Psychological Services to keep my signature on file and to charge

my credit card as indicated below for each appointment including any fees for missed

appointments or cancellations without 24hour notice.

_____ All visits this year

_____ Account Balance Payoff

_____ Other as indicated: ____________________________________________

CARDHOLDER SIGNATURE:

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Parent category: Business