Authorized Clients

Names of clients to utilize this payment method. (Please list the first and last names) *

Billing Address

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Payment

Credit Card Type *

Name on Card *

Credit Card Number *

Expiration Date *

cvv *

By signing below, I/We authorize and agree to have CCBH utilize the aforementioned credit card and/or Venmo to charge current and future bills that arise from services rendered. I/We authorize CCBH to charge the creidt card on file for any and all past due balances.

Signature *

clear

Venmo

What is the preferred method of billing? *

Special Instructions/Notes