Signed Receipt for Services

Your debit or credit card has been charged for professional services provided to you as follows: Type of Card: VISA, MasterCard or.Discover
Date of Service ___________ _____________________________
Card Holder Name
Type of Service __________________
Total Charged $___________ _____________________________
Authorized User, if different
Services Provided by:
Name ___________________________ _____________________________
Card Number
Address _________________________
________________________________ ______________
Expiration Date
Phone ___________________ ______________________________
Signature of Patient or Card Holder
I acknowledge receiving the above service, and authorizing provider to charge my debit or credit card.

These charges will appear on your monthly card statement as

and not the name of your provider or the services rendered.