I, {name}, as a cardholder, hereby authorize Dr. Chandler to charge my credit card for cancellations that are made within less than 48 hours, no-shows, and for any outstanding/unpaid invoices. The cancellation fee charged to my card will be 50% of the fee of my appointment. Certain exclusions can include inclement weather (ice, snow), illness (verified by a Dr. note), or death in the family. This credit card will also be used for unpaid invoices that are 7 days overdue.
I confirm that the information for the credit card and billing address is complete and accurate. I have been informed that I can cancel this authorization at any time after my scheduled appointments with Dr. Chandler.