Credit Card Authorization Form

To update your credit card on file, download and complete the authorization form below. Be sure to provide a valid cardholder signature. We are unable to accept forms with typed names in the signature field. 

Unable to print? Copies of this form are now available in our lobby. 

Credit Card Authorization Form


FORM SUBMISSION OPTIONS
  • Fax: 972-499-6935
  • Email: billing@dallasctc.com
  • Direct: at your next appointment