Credit Card Authorization Form

This authorization will remain in effect until cancelled. Please contact us to cancel at any time.

Credit Card Information

Visa

Mastercard

American Express

Cardholder Name:

Credit Card #:

Exp Date:

Security Code:

Billing Address

City

State

Billing ZIP code

Email address

I authorize JS Therapies, LLC, to charge my credit card for necessary co-pays, deductible amounts, and other charges not covered by my insurance that are deemed to be patient responsibility. I authorize JS Therapies to save this information for recurring payments on my account.

Child's name

Signature

Date

Your information will be encrypted.