If you would like to enjoy the convenience of automatic billing, simply complete the Credit Card Information section below and sign the form. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your monthly credit card statement. You may cancel this automatic billing authorization at any time by contacting us.

Client Billing Authorization

  • Customer Information

  • Payment Information

    I authorize Audiology Ignite to automatically bill the card or charge the ACH account listed below as specified:
  • MM slash DD slash YYYY
  • Credit Card Information

  • ACH Billing Information

    I authorize Audiology Ignite to electronically debit my bank account according to the terms outlined below. I acknowledge that electronic debits against my account must Comply with United States law.
  • Approval

  • MM slash DD slash YYYY