Credit card information

We require payment by credit card and accept Visa and Mastercard. Please complete the following information and provide your legal signature by entering your initials below.

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Credit card type*
- Visa
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Credit card number*
Expiration date*
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Security code*
3 digit code found on the back of the card
Billing Name*
First Last
Billing Address*
Street Address City State / Province / Region ZIP / Postal Code
I understand that I am obligated to pay Advanced Speech & Language Therapy, LLC for all services we render to me or my child. My initials serve as my legal signature and by signing, I authorize you to charge my credit card for your professional services.*

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Today's date*