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.
Notice:

These charges will appear on your monthly card statement as 

ProfessionalCharges.com

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