ELECTRONIC PAYMENT AUTHORIZATION
The debit or credit card information you provide on this form will only be used if you do not show for your appointment or do not cancel in the required timeframe. Please indicate the form of payment you wish to use for any services rendered through this practice. The following forms of credit cards are accepted: Visa, MasterCard, and American Express. Cash, check, Venmo, and Pay Pal are also accepted. Service fees will be deducted from the designated account at the time services are rendered. Payment is due at the beginning of each session.