Credit Card Permission Form

Patient Name:

Date:

Full name as seen on credit card:

American Express: Discover: Master Card: Visa:

Card #:

Expiration date on card:

CVV Code:

Payee Phone Number:

Billing address on card:

City:

State:

Zipcode:

I give Statesboro Psychiatric Associates permission to charge the above credit card for payments due after each visit, and for any balances to include charges incurred due to appointments missed or canceled without appropriate notice.

Signature of Cardholder:

Date:

If I have questions about these charges, I agree to contact Statesboro Psychiatric Associates. I agree that I will not pursue a refund directly through my credit/debit card company, bank, or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay any and all penalty fee(s) incurred by Statesboro Psychiatric Associates. I also understand that my card information will be kept secure.

Signature of Cardholder:

Date:

Submit Form

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