Payment Authorization

By completing this form, I authorize The Moment to charge this credit card for the cost of treatment and any ancillary expenses pertaining to the patient named below, with the understanding that there is a 24-hour change/cancellation policy (Monday appointments must be changed/cancelled on Fridays, 24 hours prior), and that missed/late cancelled appointments will be charged at the usual rate. I understand that all charges will appear on my credit card statement as Stacy A Cohen, MD CORP.

Patient Name*

Card Holder's Email*

example@example.com

Zip Code*

I understand that I can revoke or change this authorization (to the extent that it has not already been relied upon) by delivering a written statement to The Moment.

Today's Date*

Credit Card Info*

Intake

Intake | Credit on File$0.50

$ 0.50 Fee to hold card on file, total intake fees assessed, charged at appointment confirmation.

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature*

sign here