Credit Card Payment Form

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This field is for validation purposes and should be left unchanged.
I authorize Jonah Green and Associates, LLC to charge this credit card for each service, unless otherwise specified. Beginning August 1, 2020, credit card charges will include a 3% processing fee.
Card Holder Information
Patient Name*
Phone*
Card Information*
Card #*
Expiration Date*
House Number*
Zip Code*
3-Digit Code*
Cardholder Name*
Cardholder Signature*
Date*
MM slash DD slash YYYY
Email*
Therapist*
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Updated: 7/10/2020

Card Holder Information