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.

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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.*
Are you the cardholder?*
Billing address*
This field is for validation purposes and should be left unchanged.