I hereby authorize Lifetime Insight LLC to charge the credit card provided below for appointments (deductibles, copays, co-insurance, non-covered services, etc), sessions, and services, or for other reasons as stated in Lifetime Insight Consent, Policies & Payment Agreement.
I understand that this card will be stored securely and will be AUTOMATICALLY charged for no-shows or late cancellations at the following rates:
• 45–60 minute scheduled visit: $400
• 25 minute scheduled visit ("extended follow-up"): $250
• 15 minute scheduled visit ("brief follow-up"): $175
Once submitted, I understand that I will be directed to a secure form to enter my credit or debit card information. This card will be stored securely with a PCI-compliant processor, Stax, and used only in accordance with the authorization terms above.