Credit Card Authorization Form | New Patterns Therapy

CANCELLATION POLICY FORM

Card type:

Cardholder name (as shown on card): *

Expiration date: *

Card number:

CVV code

Cardholder zip code:

I,authorize New Patterns Therapy to charge $70 from my card above in case of a no show for the appointment or a late cancelation (less than 72 hours prior to the appointment). I understand that if my insurance won’t cover the sessions with New Patterns Therapy, this card will be processed to cover the balance. I also understand that my information will be saved on file for future transactions in case of issues mentioned above.I,authorize New Patterns Therapy to charge $70 from my card above in case of a no show for the appointment or a late cancelation (less than 72 hours prior to the appointment). I understand that if my insurance won’t cover the sessions with New Patterns Therapy, this card will be processed to cover the balance. I also understand that my information will be saved on file for future transactions in case of issues mentioned above.

Confirm

CANCELLATION POLICY

FORM

CANCELLATION POLICY FORM

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