Payment Authorization Form
Thank you for your payment.
Client Name
*
First Name
Last Name
Phone Number on file is
*
Please enter a valid phone number.
What Office are you Enrolled in?
Chico Office
Red Bluff Office
What is your monthly payment amount?
*
Monthly Payment + Additional Fees (Missed Activity Fee $33, Reschedule Fee $17, Late Fee $27 or LOA $20) Additional Fees are due in the month they occur.
*
Signature
*
I approve the above payment
Continue
Should be Empty: