Credit Card Payment Authorization

As a courtesy, we offer our clients the option for their session fees to be charged directly to their credit card.  The Credit Card Payment Authorization form allows MCPST Management Corporation to bill your credit card for services.  This form is kept confidential and private.  If you would like to set up this kind of payment, please complete this form and bring it with you to your appointment.  You may opt out of this service at any time.  If you have any questions about this form, please contact our Office Manager Sheena at (608) 237-8004.

*This form can be filled out on your computer if you prefer. Be sure to download and save the form to your computer first or you will lose what you typed. Click the down arrow to download the form and open it with your computer’s PDF viewer (such as Adobe Reader) – NOT your internet browser. Fill out the form, save the file and print it to sign and return to us.