Credit Card Authorization Agreement-Adult I,(Required) am the holder of Check One Please(Required) Visa MasterCard Discover Cardholder name(Required)Card number:(Required)Expiration date:(Required)Card Holder’s Zip Code:InitialI authorize the Petit Psychiatry to charge my credit card.(Required) Yes No I understand and agree that the Petit Psychiatry will charge my credit card $75.00 fee if I do not attend the appointment.(Required) I understand and agree that the Petit Psychiatry will charge my credit card for any outstanding balance past 30 days from date on my invoice. *(Required) I understand that if the above card information is incorrect or is denied I will be charged a $50 fee due immediately(Required) I understand my insurance will not pay for late cancels, missed appointments or fees and I will be responsible for payment.(Required) I understand that if I refuse to leave a valid card on file, I must pay all balances within 30 days, or I will be discharged from the Petit Psychiatry and I will no longer receive treatment including: medication management and/or psychotherapy. I also understand that all no-show fees are due the same day or I cannot schedule a new appointment and any current appointments will be cancelled until the fee is paid.(Required) I hereby authorize the Petit Psychiatry to process my credit card with their merchant services. I understand that the Petit Psychiatry is not responsible for any security or liability issues with merchant services. *(Required) I have read this entire agreement and understand that I will be held fully responsible for its terms and charges, and I agree that all charges are final and that there are no refunds for services rendered.Please Print Patient’s Name Here(Required) First Last Email(Required) Date MM slash DD slash YYYY SIGNATURE(Required)
