Credit Card Authorization
Innovative Speech and Language Pathology accepts; VISA, MASTERCARD, AMERICAN EXPRESS and
DISCOVER for payment of fees. If you would like to pay by credit card and have your credit card information
kept on file for future payment(s) simply complete and sign this form.


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CLIENT INFORMATION
Please enter the name of the client this payment is being made for:
If this payment is being made on behalf of a child, please enter the child's name below.
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First Name: *
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