Credit Card Authorization

I request that all clients provide their credit card information below and update the information with me as needed. This information will be kept in a secure place. I accept Visa and MasterCard. Charges will be applied to your credit card for the following:

  • If you choose to pay by credit card for your regular appointments a charge will be applied to your card after each completed service.
  • Missed appointments and/or appointments that have not been cancelled with one full business day notice.
  • Telephone consultations lasting longer than ten minutes (with you, other professionals involved in your care, or anyone whom you have authorized me to speak to).
  • The full amount of any returned check plus the bank charges.
  • Outstanding balances beyond 60 days, including late fees.

Credit/Debit Card Type (circle one):

  • Visa
  • MasterCard

 

Name (as printed on the card) *
Name (as printed on the card)
Expiration Date *
Expiration Date
Billing Address
Billing Address
Authorization *
By checking yes below I authorize Dr. Matty A. Wilsey to bill my credit card at the usual fee for professional services as described above.