Consent and Terms:
I Authorize Neptune Adult Medicine and its payment processor to charge my card for services provided including applicable taxes/fees.
Authorize storage of my card for the purposes indicated, until I revoke in writing. I may revoke recurring/ stored-card authorization by written notice; revocation will not affect charges already incurred.
Confirm I am the cardholder or an authorized user and that billing information is accurate. I will notify Neptune Adult Medicine of any changes.
Understand charges will follow the practice’s financial and refund policies. For questions or disputes, I will contact the office within [30] days of the charge.
Acknowledge that an electronic or photocopy of this authorization is as valid as the original. I will receive a receipt upon request or via email if on file.
Understand card data will be handled in accordance with applicable PCI-DSS standards.