Credit Card Authorization

In adherence with our clinic policy, we require each patient to keep a credit card authorization form on file in the event that you cannot or do not pay fees that are outstanding or remain as part of your visit or as it pertains to any late/no show fees. In this event, we reserve the right to authorize your credit card. Your signature below indicates your agreement and consent to charge your credit card for any outstanding charges for any service fees which may include late appointments, no shows/cancellations within 24 hours of your appointment, outstanding balances and other fees as outlined in clinic policies and procedures.

* New patient appointments require a $100 deposit to secure the appointment. Without the deposit, you cannot make a new patient appointment.