Payment Card Info - Bright Care Christian Counseling

Payment Card Entry Form

We require a payment card to be kept on file for any payments owed. By paying via credit card, you acknowledge that this payment card information will be kept on file via PCI-compliant encrypted code with Card Pointe. The client will have access to the Therapy Appointment patient portal to view the account and request statements.

CLIENT's Legal Name *

First

Last

CARDHOLDER's name (as stated on card) *

First

Last

Company Name (Optional)

Card Type *

Debit
Credit
Prepaid/Other (Cashapp, Venmo, Paypal, Bluebird, Chime, etc.)

Card Number *

Security Code (CVV) *

Expiration *

Billing Address 1 *

Billing Address 2 (Apt/suite)

City *

State *

Zip *

Email *

Phone

Bright Care Christian Counseling is in Oklahoma City, OK and provides counseling services for all ages. We offer specialists in mood and personality disorders, family matters, couples counseling, and youth issues. Feel free to contact us for more information or to schedule an appointment.