We require a credit card on file to hold your scheduled appointments and for any cancellation or missed appointment fees as set forth in our Financial and Cancellation Policies. Please complete all applicable fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.
By signing the credit card authorization form, I authorize DripLifeIV LLC to capture my credit card information and securely store my credit card on file. I authorize DripLifeIV LLC to charge my credit card on file for healthcare services provided by Deacon Medical Corp. and its contracted healthcare providers.
I understand that this may include amounts resulting from balances related to treatment, add-ons, untimely cancellations, missed appointments, non-refundable scheduling fees, or cancellations due to unsuitability of treatment not disclosed prior to scheduling as set forth in the Financial and Cancellation Policy.
I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form.