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Card Authorization Form

Jennifer Daniels, PhD, LCPC
175 Olde Half Day Road, Suite 140-9
Lincolnshire IL 60069

Debit/Credit Authorization Form

Name on the Card:

Type of Card:

Visa

Mastercard

Discover

American Express

Account Number:

Expiration Date: Security Code:

Billing Address:

City: State: Zip:

By signing this form you authorize charges to your card for:

The amount of each session

The amount of copay for each session

The amount of a missed session

Your signature also authorizes charges for the balance owed on your account should you fail to make payments by debit/credit card or by other means in a timely manner.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Type In Signature

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

August 13, 2021 5:51 am CST

Card Authorization Form Uploaded by Jennifer Daniels - jennifer@jdanielsphd.com IP 72.207.59.93