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:

  • American Express
    Discover
    MasterCard
    Visa
     
  • 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.