Cherish Payment Form

Payment Form
Name of the client*

First NameLast Name

My Products*

Screening Deposit

For pediatric screening service

$160CAD

Sensory Screening Deposit

This is the non-refundable deposit for sensory assessment. If you are accessing this service through third-party funding, you are not required to make the deposit.

$500CAD

Speech Assessment Deposit

This is the non-refundable deposit for speech assessment. If you are accessing this service through third-party funding, you are not required to make the deposit.

$500CAD

Psychoeducational Consult Deposit

This Service is a non-refundable deposit for psychoeducational consultation. If you are accessing this service through third-party funding, you are not required to make a deposit.

$500CAD

Total

$0.00CAD

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

E-mail*
example@example.com
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Purchase date
DIYdeposit
Should be Empty: