Credit Card Agreement FormI authorize the credit card that I uploaded to IVYPAY to be charged for services at Breathe Easy Therapy. I also authorize my card to be charged the no show or late cancellation fee. This fee will be the full amount of the missed session. First session you will need to show a photo ID that matches the name on the card.*Please SelectI AgreePlease Select Your Therapist*Please selectAngie VentrescaCynthia PicciniEmily Pachulska Card Number*Type*Please SelectAmerican ExpressDiscoverMastercardVisa3 Digit Security Code*Expiration Date* Date* MM slash DD slash YYYYEmail* Client Name* First Last Are you a Parent or Guardian of the Client?*Please SelectNoYesClient Signature* Parent/Guardian Signature*Δ
