RELAX YOUR MIND SERVICES

RELAX YOUR MIND SERVICES
RELAX YOUR MIND SERVICES LLC
Credit Card Pre-Authorization Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The undersigned Patient/Cardholder hereby authorizes RELAX YOUR MIND SERVICES LLC, to obtain payment of fees for services from the Patient/Cardholder's Credit Card account identified below.

RELAX YOUR MIND SERVICES LLC may charge the account to secure the patient's appointment time, for any missed/ late cancelled/late rescheduled appointments ($100 fee) (minimum of 24 hours cancellation notice is required), without requiring the Patient/ Cardholder's signature for each payment. A receipt of the transaction will be mailed to the address provided by the Patient/Cardholder above.
Credit Card Upload front*

Cancelof
Credit Card Upload back*

Cancelof
I authorize any balance to automatically be charged to this credit card.*

Yes
Card Number *
CVV (3 digits on back of card-Amex (4 digits)*
Month / Year- expiration date*
Patient/Cardholder Authorized Signature*
PatientCardholder Authorized Signature*

Clear
By signing this form, the Patient/Cardholder acknowledges and agrees as follows:

§ This signed form is confidential and will be kept on file at RELAX YOUR MIND SERVICES LLC. § The Patient/Cardholder authorizes RELAX YOUR MIND SERVICES LLC to automatically charge the above-referenced Credit Card. § The Patient/Cardholder certifies, warrants and represents that the Cardholder named above agrees to pay the credit charge(s) in accordance with the agreement described above. $ Credit Card payments will appear on your statement as RELAX YOUR MIND SERVICES LLC. § If the Patient/Cardholder fails to dispute a charge within 30 days from the time the Credit Card is charged, the Patient/Cardholder agrees that the charges are valid and agrees not to dispute said charges. § This authorization will remain valid for 12 months or until revoked in writing with 30 days notice of revocation.

frontdesk@relaxyourmindservices.com
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RELAX YOUR MIND SERVICES

RELAX YOUR MIND SERVICES LLC