Submit - Pelican Therapy Partners

Credit Authorization

Office Policy Regarding Payment

Client Name

How will you be paying for our services?

Check

Credit Card

(If you are a private pay client or have commercial insurance, credit card info is required to be on file, even if your preference is to pay by check)

If you choose pay with check, we ask that you have your check made payable to “Pelican Therapy Partners” on the last day of you/your child’s therapy each week.

If you choose to pay with credit card, please complete the authorization below, we will run your card on the last day of you/you child’s therapy each week. Also, by choosing to pay by credit card there will be a small fee that the credit card company charges us. This is 3% plus 0.30 cents.

Credit Card Authorization

Cardholder Name

Card Type

Card Number

Expiration Date

CVV Code

Cardholder Zip Code

I authorize Christy Miller LLC dba Pelican Therapy Partners to charge my credit card above for agreed upon services at the end of each week. I understand that my information will be kept on file for future transactions on my account.

Signature

Clear

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