Credit Card Authorization Form

Monthly Credit Card Authorization
The undersigned authorizes Express Yourself Speech Pathology, LLC to make the following charges to their credit card for payment of speech therapy services and/or associated expenses.
The following should be filled out in its entirety:
Child’s Name:*
Parent's Name*
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
This information must match the card or it will not process. We request that you notify our office as soon as possible if any of this information changes. This agreement will remain in effect, and your card may be charged monthly, until this agreement is cancelled in writing.
I authorize Express Yourself Speech Pathology Services, LLC to charge my credit card on a monthly basis. Express Yourself Speech Pathology Services, LLC will only submit credit card charges after my child’s treatment has occurred. I understand that Express Yourself Speech Pathology Services, LLC will send me an invoice prior to charging my credit card, so I have the ability to look over my statement. I understand that to swipe my actual card, there is a 2.75% fee and manually entered cards incur a 3.5% fee.*

Monthly Credit Card Authorization