Credit Card Authorization Form

Update your credit card on file by downloading and completing 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