Credit Card Change Form
Please fill in all required fields
"I understand and agree that all policies of Jodi Valentine Counseling will apply to this card on file. Should this new card not process for any applicable fees, I understand that any other previously added cards will be processed for such applicable fees".
Patient's Full Name
Name on Credit Card
Type of Credit Card
Credit Card Number
(CVC- 3 digit code on back of card)
Billing Address including zip code
You will receive an email receipt for any charges applied to your credit card unless otherwise requested. A super bill can also be provided for insurance purposes.
Please type your name as you would sign on your card.