credit card authorization form

Credit Card Authorization Form
Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.
Patient's Name *

My Products

Therapy ServicePlease enter the dollar amount in quantity.

$1.00 Quantity
Item subtotal:$0.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

By signing this form, I authorize Speech Therapy and Education Professionals to charge my credit card above for agreed upon purchases/services I understand that my information will be saved to file for future transactions on my account.
Customer Signature*

Clear
Date*

MonthDayYear
Date
Upload your invoice, if needed. Suba su factura, si tiene una.

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872 62nd Street Cir E, Ste 101-103

Phone: (941)251-6825 Fax: (941)201-1626
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