PATIENT NAME

TYPE OF CARD

VISAAMERICAN-EXPRESSMASTERCARDDISCOVER

CREDIT CARD NUMBER

EXPIRATION DATE

SECURITY CODE

CARD HOLDER NAME (EXACTLY AS APPEARS ON CREDIT CARD)

CARD HOLDER PHONE

CREDIT CARD BILLING ADDRESS

I AUTHORIZE DOROTHY MIYAOKA, LMFT TO KEEP MY SIGNATURE ON FILE AND TO CHARGE MY CREDIT
CARD FOR MISSED APPOINTMENTS AND ANY UNPAID BALANCES FOR SERVICES ALREADY RENDERED

CARD HOLDER SIGNATURE:

DATE:

I AUTHORIZE MY CHILD OR SPOUSE TO SIGN MY CREDIT CARD FOR SERVICES PROVIDED BY DOROTHY
MIYAOKA, LMFT

CARD HOLDER SIGNATURE:

DATE: