Credit Card Charge Authorization Form
By signing this form, you give Kids Express Speech Therapy permission to debit your
account for the amount indicated on or after the indicated date. This is permission for
current and future services as outlined in this agreement and does not provide
authorization for unrelated debits or credits to your account.
Name on Card: _________________________ Email Address: ___________________________
Billing Address: _____________________________
(including zip) ______________________________
Credit Card Type:
☐ Visa ☐ Discover
☐ Mastercard ☐ American Express
☐ FSA ☐ Other _______________
Credit Card Number: _________________________________
Expiration Date: _____ Card Identification Number: ______ (3 or 4 digits on back of card)
• I authorize Kids Express Speech Therapy to charge fees rendered for services to
the credit card provided herein.
• I understand that the provided credit card will be charged for services rendered
at the end of the month and that I will receive an electronic invoice as a receipt
of payment. Printed invoices available upon request.
Cardholder, please sign and date:
Print Name: __________________________ Signature: ____________________________
Date: _____________
Credit Card Authorization
I authorize Kids Express Speech Therapy to charge the credit card indicated in this authorization form according to the
terms outlined above. This payment authorization is for therapy services, for the amount invoiced by the practice, and is
valid for ongoing monthly and weekly services. I certify that I am an authorized user of this credit card and that I will not
dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this
form.