No Show Credit Card Authorization

Please complete all fields.

You are authorizing Amarillo Medical Specialists LLP to charge your credit card $1.00 now, in order to validate your credit card and enter it in our files.

This will be credited to you at your appointment. If you do not keep an appointment, or do not provide two business days advance notice of cancelation, you are authorizing us to charge:

$100 for a new patient appointment , or,

$25 for an established patient appointment.

You may cancel this authorization at any time after your scheduled appointment by contacting us. This authorization will remain in effect until canceled.

I authorize Amarillo Medical Specialists LLP to charge my credit card above for agreed upon services. I understand that there is a no-show fee if I do not keep my patient appointments as above, and, I understand that my information will be saved to file for future transactions on my account.