Credit Card Authorization Form

JavaScript tarayıcınızda etkin olmadığı için bu dosya açılamıyor. Etkinleştirin ve yeniden yükleyin.

Ray of Hope Child Therapy Services Inc

533 Airport Blvd. #400

Burlingame, CA 94010

877-758-7257

contact@turajohnsonmft.com

İlerleme durumunu kaydetmek için Google'da oturum açın Daha fazla bilgi

E-posta *

Client Name *

Street Address *

City, State, and Zip Code *

Responsible Party Name *

As the person named above (or the person responsible for payment of this client’s fees), I hereby give my permission for Ray of Hope Child Therapy Services Inc to keep my card and signature on file and to charge my credit card account. Your card will be charged the day of the scheduled session, and for missed sessions that are not cancelled within the 48 hour policy. I understand that this form is valid unless I cancel the authorization through written notice.

Everyone is required to keep a card on file regardless if you are using EAP benefits and/or your company is paying for your services.

A $1 invoice will be sent via Square to save your card on file. Click the box to save your card. The $1 invoice will be refunded after your card is saved.

You agree to keep a valid credit card on file *

Yes

You agree that you will save a credit card that belongs to you *

Yes

You agree to not remove your card on file without notifying Admin staff. Removal of card without notifying staff will result in your appointment being on hold until a new card is added.
*

Yes

Todays Date *

YYYY

By typing my name, I agree to the above *

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Gönder

Formu temizle

Google Formlar üzerinden asla şifre göndermeyin.

Bu form Ray of Hope Child Therapy Services alanında oluşturuldu. Kötüye Kullanımı Bildirme

Formlar