One- time Payment Authorization form

  • 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.
  • 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.