I authorize Arohi Counseling

I authorize Arohi Counseling, LLC to keep my signature on file and to charge the credit card chosen below for the following

Balance remaining after claim (s) is (are)

Resolved not to exceed $

For:

This consultation only

All consultations this calendar year

All consultations from

Start Date

End Date

Recurring charges of $ to be charged every (frequency)

Start Date

Charges for the following family members

(authorized family member)

Check One:

Visa® American Express® MasterCard® Discover Card®

Patient Name

Cardholder Name:

City

State

Zip

Credit Card Number:

Exp. Date:

Date:

Cardholder Signature:

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