Credit/Debit Card Payment Authorization

I   verify that my credit card information, provided above, is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied. I also understand by signing and initialing I recognize that if my payment is not received Accepted Therapy Services reserves the right to use an attorney or collection agency to secure payment.