CREDIT CARD AUTHORIZATION FORM

Revised November 2017

* Indicates a required field

This is to authorize Center for Developing Kids as of:

TODAY'S DATE*

to make automatic credit card charges against my credit card account, until revoked, upon issuance of monthly invoices or for insurance co/pays for therapy services for my child:

CHILD'S NAME*

NAME AS IT APPEARS ON CARD*

BILLING ADDRESS*

BILLING ZIP CODE*

PHONE*

EMAIL*

A receipt will be sent to the email address listed above.

CARD TYPE*
VISAMASTERCARD
CARD INFORMATION*
Please sign below.