Amazon Web Services



The Leadership PracticeSibylle Georgianna, Ph.D. (917) 620 0481 sgeorgianna@Amy Quinn, M.A., M.S., LMFT (949) 728 8211amy@28202 Cabot Road Suite 300Laguna Niguel CA 92677Credit Card Authorization FormWe are pleased to accept Visa Card, MasterCard, and American Express, or PayPal (sgeorgianna@) for your payment today. I, (please print your name):__________________________________ consent that I make full payment of fees via PayPal to sgeorgianna@ (Initial here):_________ ORThe Leadership Practice charges my credit card account as follows: I authorize The Leadership Practice to charge my card for payment of each session and/or service at the beginning of the business day that my appointment/service is scheduled. (Initial here): _________.2. Cancellation of my appointment needs to be received before 10 a.m. U.S. Pacific Time on the previous business day to avoid a charge. (Initial here): _________.- Friday appointments need to be cancelled on the Thursday prior before 10 a.m. Pacific Time. (Initial here): _________.- Saturday appointments need to be cancelled on the Friday prior before 10 a.m. Pacific Time. (Initial here): _________.- Monday appointments need to be cancelled on the Friday prior before 10 a.m. Pacific Time. (Initial here): _________.2. I release The Leadership Practice from any and all claims arising from the charge of my credit card in accordance with this authorization. (Initial here): _________.3 If a representative of The Leadership Practice submitted my claims to an insurance carrier on my behalf I understand that I am responsible for any unreimbursed portion of the claim. (Initial here): _________.4. I understand and consent that my credit card will be charged for any unreimbursed portion of the insurance claim for any services I receive. (Initial here): _________. Credit Card Number: ___________________________________________________Visa __MasterCard__American Express Exp. ___ / ___Three-digit code on the back of card: ________Name as it appears on the card: Phone number associated with the card: Billing Address: Zip: Send receipt via email? ___ No___ YesEmail address: ________________Signature: _________________________________________ Date: ______________ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download