Credit Card Authorization Form

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Important Documents

Credit Card Authorization Form

Name

Email Address

Phone

Billing Address (Street, City, State, Zip)

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Credit Card Information

Card Type*

MasterCard

VISA

Discover

AMEX

Cardholder Name (as shown on card)

Card Number

Expiration Date (mm/yy)

Cardholder ZIP Code (from credit card billing address)

I hereby authorize Darbonshire LLC and Darby Fox, LCSW, to charge my credit card for the agreed-upon purchases. I understand that my payment information will be securely stored for future transactions related to my account.

Customer Signature

Date*

Select Date ×

Important Documents

Please review our important policies before proceeding. Click the links below to download and review.

HIPAA Notice of Privacy Practices Authorization to Use or Disclose My Health Information Terms of Service Privacy Policy

Your form has been submitted

Thank you for your authorization. Your information has been securely recorded for future transactions. If you have any questions or need assistance, please contact us.

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