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Credit Card Authorization form

Credit Card Authorization form

If you deleted or accidentally saved a version of the Credit Card Authorization form and want to revert back to the default, we've included a copy below. Just delete the text in the current Credit Card Authorization form and copy and paste the following:

Credit Card Authorization

By your electronic signature of this form, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement as [STATEMENT DESCRIPTOR]. You have the right to request a paper copy of this document.

I authorize [CUSTOMER BUSINESS NAME] to charge my credit card through Stripe. [OPTIONAL CANCELLATION POLICY: I also agree that my credit card can be charged for any session that is not cancelled at least 48 hours prior to the scheduled session].

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify [BUSINESS NAME] in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

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