Common Contracts
1 similar Credit Card Authorization Form contracts
CREDIT CARD AUTHORIZATION FORMCredit Card Authorization Form • March 25th, 2020
I, _______________________________, hereby agree to leave my charge card on file at Best Quality of Life, Inc., to be charged when/if I have a Broken Appointment, Session Fee and/or Bounced Check throughout the duration of treatment services with my clinician. By signing this form, you authorize, J Group Counseling Services, LLC., to charge your account for the amount checked above.
