Update Payment Method
Please use this form to update your payment method if you are unable to log into your client portal and fill out the shared form.
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Client Name *
Name on Card *
Card Number *
Credit Card Expiration Date *
Credit Card Security Code *
Credit Card Billing Zip Code *
I consent to Peak Professional Group, PLLC charging my credit card for balance due or agreed upon amount *
By typing my name in the box below, I acknowledge it as an electronic format of my signature *
Date Signed: *
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