ChiroSoft Payment Authorization

1. Clinic Information

Clinic Name*

Clinic Owner *

First NameLast Name

Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Clinic Phone Number*

Area CodePhone Number

Clinic Email*

example@example.com

2. Service and development fees authorization

$65.00 CAD/M

The service and development fees include:

Technical support on Chirosoft
At distance/remote training on Chirosoft
Chirosoft updates
Migration from Chirosoft to the web version when available, including data transfer.

This agreement will be of a minimum duration of three (3) months from the signature date. This agreement will be in effect until the subscriber cancels with a 30-day written notice after the 3 months agreement period. The notice can be sent via email to admin@chirosoft.ca.

I accept and agree to pay the monthly service and development fee. Please select a payment option below and provide requested information.

YesNo

3. Payment option

I want to pay via

Auto DebitCredit Card

To pay via Auto Debit:

You can email us a voided check or supply the following information:

Account Type

CheckingSavings

Bank Name

Transit Number

Account Number

Pre-Authorized Debit Agreement You acknowledge that the authorization is to allow the business with whom your agreement is with to debit funds from your bank/credit union account for regular or recurring payments and/or one-time payments based on your payment obligations to the business with whom your agreement is with.

YOU WAIVE ANY LEGISLATIVE OR REGULATORY REQUIREMENT FOR PRE-NOTIFICATION.

Transaction dates that fall on a weekend or holiday will be processed the next business day. You understand this is a personal PAD agreement.

You may revoke your authorization at any time, subject to providing notice 30 business days before the next scheduled debit. You can obtain a sample cancellation form or more information on your rights to cancel a PAD agreement at your financial institution or by visiting the www.payments.ca/paying-pre-authorized-debit. You can also reach out directly to us and cancel your authorization.

You have certain recourse rights if any debit does not comply with this agreement (because the debit was not withdrawn in accordance with this authorization or amounts were withdrawn after the agreement was revoked). For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement based on the timeline set out by the Canadian Payment Association. To obtain more information on your recourse rights, contact your financial institution or the Canadian Payment Association.

To pay via credit card:

Please complete below the best date, time, and contact number for our accounts team to contact you for the card details, or give us a call at 1-418-627-6128 (Quebec Region), 1-877-202-4476 (Outside Quebec Region) or 1-888-880-8602 (International - English), Monday thru Friday between the hours of 8:00 am - 5:00 pm EST

Contact Number#

Date

Time

:HourMinutesAM/PM Option

4. Signature of the authorized person

Signature*

Name

First NameLast Name

Enter the message as it's shown*

Authorization and Payment option for the Service Fees

1. Clinic Information

2. Service and development fees authorization

3. Payment option

4. Signature of the authorized person