All credit card payments require written consent by the authorized party, Your signature on this form indicates that you are the authorized person to use the designated credit card and authorize Tracy L. Helmer, Psy.D. to use your credit card to process payments for services rendered. In the event that you wish to discontinue this authorization, or, if your credit card information changes, you must notify me as soon as possible and we will complete the necessary forms to make the changes. Changes will only be accepted in writing.

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