Credit Card Authorization
In order to hold your appointment with Amy Sharma or Geoffrey Fong, we ask that you place a credit card on file. In the case that an appointment is cancelled outside of our policy (see below), you will be charged for the cost of the appointment ($300 for intake appointments, $150 for follow up appointments).

This form is secure and submits your payment information directly to an encrypted database.

Email address *
Client Name *
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Name on Credit Card *
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Credit Card Number *
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CSV *
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Credit Card Expiration Month *
Credit Card Expiration Year *
Billing Zip Code *
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By Typing Your Name You Agree the Above Information is Correct *
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Summary of Cancellation Policy
Except in the case of an acute emergency or illness, we require a two business days notice for any cancellation; otherwise, your account will be charged for the visit. If our office is closed, leave a message on our office voice mail, the Valant portal, or send us an email to inform us of your cancellation.

***CANCELLATION POLICY***

We have a two-day, two-tier cancellation notice policy.

If you need to cancel or reschedule with less than 48 hours notice, you will be charged $50.

If you contact us within 24 hours of your appointment, you will charged your full appointment fee ($300 for intake appointments and $150 for follow up appointments)

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