Credit/Debit Card Payment Consent Form 

Client Name ____________________________________________________


Print Last


Middle Initial

Name on Card if different ___________________________________________

I authorize ____________________________ and

Provider Name

to charge my card  for professional services for  


the amount of $__________________.

Type of Card: VISA  MasterCard.Discover Exp. Date __________
Card Number _______ - _______ - _______ - _______  CVV Number  ______
Card Holder's Billing Address for Monthly Card Statements
Street City State Zip
If I have questions about these charges, I agree to contact my provider and if necessary via email ( I agree that I will not pursue a refund directly through my credit/debit card company, bank, or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay any and all penalty fee(s) incurred by my provider.
Card Holder Signature ____________________________ Date ____ /____ /____

Charges may appear on your card statement as an abbreviation of usually