Credit Card Authorization Form

Credit Card Authorization Form

1 2

We use Square to securely store your payment information and charge your card. HSA and FSA cards are now accepted.

Child's first and last name (or name of Adult receiving services):*

Name of person filling out form:*

Relationship to client:*

Your phone:*

Your Email:*

Cardholder Name (as shown on card):*

Billing street address:*

City:*

State:*

Zip code:*

Credit card number:*

Expiration date:*

Credit Card Security code:*

Authorization:

I hereby authorize Gold Speech, Inc. to charge the indicated credit card. I am aware of the company policy requiring cancellation by 7:00 a.m., if not sooner, the day of the scheduled session, to avoid the session charge. I am aware that I cannot receive reimbursement from my medical insurance for late cancellation fees of missed sessions. I agree that this is either a recurring or one-time charge that will be made, and I will not dispute it in the future. To terminate the recurring billing process, I must cancel in writing, preferably with 2 weeks notice.

I agree to the terms Type your name as your electronic signature:*

Optional comment:

Home practice strategies for carryover
Sibling, parent, grandparent participation
Collaboration with teachers, psychologists, physicians

Credit Card Authorization Form

CONNECT WITH US

Follow us