One- time Payment Authorization form "*" indicates required fields One-time Payment Authorization form This form is for patients who would like to use a credit card that is different from what they have on file. This is for a one- time payment and this card would not be kept on file. Name* First Last Email Address* Date* MM slash DD slash YYYY Authorization By signing below, I understand that I am authorizing Atlantic Counseling & Consultation, Inc to charge the credit card information on this form for a one- time amount which is also specified on this form. I understand that Atlantic Counseling & Consultation, Inc will not put this card on file. I understand that if I am a new or current patient, that the office policy is to have a credit card on file. I have read the statement and authorize my credit card to be used.* Yes No Cardholder signature* Are you the cardholder?* Yes No If you are not the cardholder, what is your relationship to the cardholder?* Billing address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Credit card numberExpiration date (mm/yy)* CVV* Amount to be charged to credit card* NameThis field is for validation purposes and should be left unchanged.