DEBIT/Credit Card Authorization Form

DEBIT/Credit Card Authorization Form
Cardholder Name*

First NameLast Name
Credit Card Type*
If Other, Please write the Credit Card Type
Account Number*
Expiration Date*
Security Code*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that a no-show fee of $50 applies after a late cancellation (see Clinic Policy), and my credit/debit card will be automatically charged for this fee.

I authorize Elevated Image & Primary Care to charge my credit card for additional services provided to patient, for services not paid by insurance carrier and which are considered concierge services as noted under payment terms and uncovered services. Charges to this credit card may include but are not limited to office visits, phone sessions, paperwork ($15/ page), and late cancellation or no-show fees. I understand my credit/debid card will be automatically charged for these services and I will contact the office prior to my visit if I need to change cards on file. *
Date

MonthDayYear
Date
Cardholder Signature*

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