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Credit Card Authorization Form
We only accept VISA or Mastercard.
Email address
Patient Name
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Visa or Mastercard
Credit Card Number
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Expiration Date
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Security Code
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Billing Zip Code
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Light on Anxiety Therapist
I authorize the payment of fees to Light on Anxiety, for services rendered. I authorize that my card is used to resolve any and all balances in full on my account for individual or consultative charges, missed/ or forgotten payments, and/or appointments cancelled/no­show within 24 hours of scheduled appointment time. I understand that this cancellation fee is not covered by insurance. I understand that payment is required at the time of service. I understand that I am required to provide up to date credit card information on file for regular appointment payments, forgotten payments, missed appointments, and out of office appointments. I understand that late payments may be subject to an additional late payment fee and ongoing noncompliance with payment terms may incur collections charges if I do not provide timely payment to resolve my balance.
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