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Credit Card Authorization Form

Crossroads Behavioral Health Services
1003 Cottonwood Rd
Phone 641-782-8457
Creston
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
****THERE WILL BE A 3.95% FEE FOR ALL CARD PAYMENTS****
Cardholder Name
Client name
Billing address
Credit card type
Visa   Mastercard   Discover  
AmEx     
Credit card number
Expiration date
Card identification number (3 digits on the back)
Amount to be charged
Additional Notes
***DISCLAIMER*** Please allow 1-3 business days for payment processing.
I authorize Crossroads Behavioral Health Services to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this service in accordance with the issuing bank cardholder agreement.
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
FOR OFFICE USE ONLY
Processed by
Process date
Form Updates
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  2. Click the "Cancel" button to exit without saving recent updates on this form.