Clearwave Mental Health Credit Card Authorization Form

Clearwave Mental Health Credit Card Authorizaton Form
Date*

MonthDayYear
Date
Patient Name*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile #*
Email Address*
example@example.com
Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

My Products*

Clearwave Mental Health ServicesYour card will not be charged until date of services

$1.00

Total

$0.00

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

I hereby authorize Riverview Psychiatric Medicine PC d/b/a Clearwave Psychiatry (“Clearwave”) to keep my signature on file and charge the provided credit card for services rendered.
Signature*

Clear
Should be Empty: