Credit card authorization

Oliver Parkes Therapy LLC.

Credit Card Authorization Form
* indicates a required field

Card Type
Master Card
Visa
Discover
Amex
Other

* Cardholder Name (as shown on card)

* Card Number

* Security Code

* Expiration Date

* Cardholder Zip (from credit card billing address)

* Email for receipt to be sent
By e-signing below, I authorize Oliver Parkes LCPC-c to charge my credit/debit card for the following:
- Individual, couples, or family counseling/consultation sessions
- For any appointments missed or canceled with less than 24 hours’ notice
- Copay or coinsurance rate for all attended appointments
- Any portion of billable services not covered by client's insurance policy

I understand that payment is due at the time of service, including treatment expenses not covered by insurance, missed appointments, and copayments. I will have the option of paying with check, cash or credit card at the time of service. If I have an outstanding balance or a missed appointment, I authorize to use this credit card information as payment for services.