Print out this form. Have Cardholder complete and sign it. Keep signed original.

Credit/Debit Card Payment Consent Form 

Patient Name ____________________________________________________

.

Print Last

First

Middle Initial

Name on Card if different ___________________________________________

.
I authorize ____________________________ and ProfessionalCharges.com
.

Provider Name
to charge my card for professional services as follows:

 Initial

______

This visit only, for the amount of $__________________.
. .

______

 All visits in the next 12 months, beginning _____ /_____ /_____, 
. not to exceed $____________ total.
.

______

 Recurring charges, date(s) of service _____ /_____ /_____ to
. _____ /_____ /_____, not to exceed $____________,
. ____ monthly, ____ semimonthly, ____ weekly, ____ per visit.
.

______

 to charge my card for the balance of fees not paid by my insurance company within 90 days, as indicated above.
Type of Card: VISA  MasterCard.Discover Exp. Date ____________
.
Card Number _______ - _______ - _______ - _______  CVV Number ________
.
Card Holder's Billing Address for Monthly Card Statements
 
___________________________________________________________________
Street City State Zip
.
If I have questions about these charges, I agree to contact my provider and if necessary ProfessionalCharges.com via email (info@professionalcharges.com). I agree that I will not pursue a refund directly through my credit/debit card company, bank, or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay any and all penalty fee(s) incurred by my provider.
Card Holder Signature ____________________________ Date ____ /____ /____

Charges will appear on your card statement as an abbreviation of  ProfessionalCharges.com usually ProfCharges.com
 

ProfessionalCharges.com
1530 E. Chevy Chase Dr., Suite 209
Glendale, CA 91206

Phone:  (818) 206-2126

HomelBack to How It Works