Payment Authorization

"*" indicates required fields

Fill in all the required fields and sign the form to put your credit card on file.

Client First Name*

Client Last Name*

Client Date of Birth*

Office Location*

Mobile Phone*

Email

Not the client? (Ex: Parent/Guardian/Spouse of the client)

I am not the client, but a Responsible Party for for the client.

Responsible Party First Name*

Responsible Party Last Name*

Cardholder's Name*

Type of Card*

Card Number*

Expiration Date*

CVC*

Billing Zip Code*

Phone

This field is for validation purposes and should be left unchanged.