Credit Card Authorization Form

Please complete the form below

Cardholder Name

First Name

Last Name

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Credit Card Type

Credit Card Number

Expiration Month

Expiration Year

Security Code

Cardholder Approval

By submitting your name, this serves as your e-signature that you understand that each 45 minute session is $150. Charges by this office will only be made with your permission.

First Name

Last Name