Toensing Family Chiropractic

CREDIT CARD AUTHORIZATION

I ____________________________, authorize Toensing Family Chiropractic
to keep my signature on file and to charge my credit/debit card listed below for:

_________ All patient/client balances (less that $250.00) for services rendered
once the claim has been processed by my insurance company.  
I understand that TFC will contact me by phone for all balances exceeding $250.00
prior to charging my card.  Preferred Contact Number______________________________

________ Recurring charges for services rendered for the following family members:

Patient Name _________________________________________ DOB______________

Patient Name _________________________________________ DOB ______________

Patient Name _________________________________________ DOB ______________

Patient Name _________________________________________ DOB ______________

Check one   Visa _____   Mastercard _____   Discover _____ American Express* _____

* I am waiving the 10 day prior notification for any transaction processed on my American Express card.

* AMEX Cardholder Signature ____________________________________ Date _________

Visa, MC, Discover Cardholder Signature ___________________________ Date _________

Cardholder Name  ___________________________________________________________

Billing Address ______________________________________________________________

City ______________________________ State ______________  Zip __________________

Credit Card Number ________________________________   Expiration Date ___________

CVV # ___________3 numbers on the back of the card or 4 numbers on the front for American Express

Contact TFC at 844-772-6363 to terminate this authorization at any time.