I, First Name* Last Name* of Street Address* Address Line 2* City* State* Zip* hereby consent and authorise the use of my credit card/bank account for the purpose of paying the medical fees of First Name* Last Name* (DOB Date* )(hereby known as 'the patient'). The medical fees may include but are not limited to physician fees, and any related medical expenses incurred on behalf of the patient.I understand that my credit card/bank account information will be used solely for the purpose of settling the medical expenses of the patient. I agree to be responsible for any charges incurred and authorise WillowVale Clinic to charge my credit card/bank account accordingly. WillowVale Clinic will inform me or the patient before the amount is charged, and a receipt will be sent electronically after the amount is charged. I acknowledge that this consent is voluntary and that I have the right to revoke it at any time by providing written notice to WillowVale Clinic.Thank you kindly,