EmailMe Form - CREDIT CARD AUTHORIZATION

EmailMeForm

CREDIT CARD AUTHORIZATION
Please complete this form if you wish to pay for appointments with Dr. Sarah Allen using a credit card.
Rather than complete a new form after each session, by completing these details you agree that the card will be used for payment the day of each session unless other arrangements are made.
Visa & Mastercard are accepted. AMEX is not accepted at this time.
From today’s date: *
MM / DD / YYYY
Credit Card *

Card Number

Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
Authorization of Charges *
I do authorize
I authorize the use of my credit card to the amount of $ 200 for the assessment and $ 165 after each 45 minute appointment or $200 for each 55 minute appointment with Dr. Sarah Allen
CARDHOLDER
Complete all fields below:
✓ Full Name (as it appears on card): *
First Middle Last
✓ Billing Address (address where statement is mailed): *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
✓ Area Code/Phone: *
### - ### - ####
I hereby confirm the above transaction is authorized and that I have either received the services or my card has been charged because my appointment was canceled outside of the cancelation time frame as outlined in the Rescheduling/Cancelation policy that I have signed. I understand that this transaction is non-refundable & will not be disputed by the card issuing bank. *
I do authorize
Cardholder Signature: *
Clear
Above must be signed by cardholder (authorized user).

CREDIT CARD AUTHORIZATION

CARDHOLDER