Credit Card Authorization

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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)

First Name

Last Name

Credit Card Number

Expiration Date

MM

DD

YYYY

CVV Code (3 digits, as it appears on the back of the credit card)

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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.

Yes

No

Credit Card Authorization

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