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):