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Credit Card Authorization Form

LifeBack
4 Princess Rd
Suite 206
Lawrenceville, New Jersey 08648
Phone 609-482-3701
Fax 609-482-3702
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Authorization Information
By signing this form, I am authorizing LifeBack to charge the credit/debit card I have placed on file.

If authorizing my card to be charged on more than one occasion, I understand that my information will be saved in my Electronic Medical Record for future transactions.  

I understand that my card will be charged after each visit in the office or via tele-session.
* In the event of a late cancelation or no show:
I am authorizing my card to be charged in the event of a late cancelation or appointment no show.  
I do not want my card to be charged in the event of a late cancelation or appointment no show, I would like the Billing Department to contact me directly for payment authorization.  
Credit Card Information
* Name on Card
* Type of Card    if selecting Other, please write type of card
Visa   Mastercard   American Express  
Discover   Other    
* Account Number
* Expiration Date (MM/YYYY)
* Security Code
* Billing Address
* City, State, Zip Code
* Phone Number
* Email Address
Please use the field below to add Authorized Card Holder's signature. If card holder is someone other than Patient, please select "Other" as "Signer Type" and type in Card Holder's full name. If signing from home, press "Sign with Touch" and utilize mouse, trackpad, or touchscreen to write signature.
* Authorized Card Holder Signature
Signer Type:
Name:
Signature:
Sign with Touch
 
Comments:
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