J. Gregory Turnbull, Psy.D., J.D.
Psychologist in private practice in Kailua, Hawaii
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Credit Card Authorization
Credit Card Authorization Form
This authorizes Dr. Turnbull to bill your credit/debit card for services without you having to present your card physically in person.
NO INFORMATION IS STORED ONLINE.
Cardholder
*
Name as it appears on the card
Card Type
*
Visa
MasterCard
Discover Card
AMEX
other
Card Number
*
Card Expiration Date. (mm/yy)
*
Security Code
*
Cardholder Billing Zipcode
*
Consent
*
Consent
I authorize Dr. Turnbull to charge my credit/debit card for agreed upon purchases. I understand that my information will be saved for future transactions on my account.
Email
This field is for validation purposes and should be left unchanged.