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Credit Card Authorization Form

Credit Card Authorization Form

Please complete all fields. A credit or debit card on file is required to schedule, maintain, and ensure appointments You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled or until the expiration of the credit card account.

Credit Card Information

I Authorize Dr S Weightloss & Wellness to process the above credit card as ?Card on File.? The Card on File will be charged for in office visits, telemedicine visits, missed appointments and cancellations outside the 48 hour policy. I authorize Dr S Weightloss & Wellness to charge my credit card above for copays for future appointments, payments towards balance, coinsurance, missed appointments fees, and other payment?s that are patient?s responsibility, at a set amount approved by patient first. I understand that my information will be saved to file for future transactions on my account.

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Missed appointments including coaching: If you are unable to keep an appointment with our practice, please notify us at least 48 hours in advance of your appointment. Failure to do so will result in a $150.00 charge for new patient appointments.. There is a $80 charge for medical follow up appointments, and a $50 charge for coaching. All missed appointment fees must be paid prior to your next visit. Three missed or last minute cancellation to appointments in a row will result in being discharged from the practice. Exceptions may apply!
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