Credit Card Authorization Form
Please complete this form by indicating a check mark in each section that would be an acceptable manner in which our practice can contact you.
I wish to be contacted by Cordell Associates, LLC, herein after referred to as “provider”, in the following manner (please check and complete all areas that would be an acceptable manner for Cordell Associates, LLC to contact you):
(Leave blank if you do not wish to be contacted via email.)
Provider can mail me information such as statements, appointment reminders or my requests for information to the following address:
Client's Name (Please print)
Thanks for submitting!