CREDIT CARD AGREEMENT

I,, give Ther-Ex Unlimited, Inc. the authorization to charge the below provided credit card for my co-payment as agreed. If my insurance reimburses me for services rendered by Ther-Ex Unlimited, Inc. I am to forward the checks to the corporation. In case that I do not forward checks to Ther-Ex Unlimited they also have the authorization to charge my credit card.

Card Holder's Name :

Card Type: Visa Master Card American Express

Credit Card Number: 

Expiration Date:  /

Card Holder’s Signature:

I agree and understand the terms and condition that apply

Signature XPRINT