Credit/Debit Card Authorization Child NameParent NameI authorize Advantage Speech Therapy Services to maintain my credit/debit card on file. I understand that this card will only be used if:My child’s account has been delinquent for more than 30 days and I have not made any effort to make payment arrangements.*YESNOMy child’s appointment was canceled with less than 24 hours notice.*($55 or 50% of insurance rate-per policy form)YESNOIt was a no show for a scheduled appointment.*($55 or 50% of insurance rate-per policy form)YESNOI want to set up automatic payments when an invoice is created.*YESNO *There will be a processing fee attached to the use of your card. Date Date Format: MM slash DD slash YYYY Patient Name:*Cardholder Name:*Cardholder Address:*City:*State:*Zip:*Type of CardVisaMastercardAmexCard#*Expiration:*CVV:*EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
