VITALITY PSYCHIATRY GROUP PRACTICE
CREDIT/DEBIT CARD AUTHORIZATION
  • Legal name as on government issued identification.
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    Please enter the patient's Date of Birth
  • Please enter the address that is on file with the card.
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  • I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Vitality Physicians Group Practice PC in writing of any changes in my account information or termination of this authorization. It is expressly understood that the amount charged does not include or constitute any additional fees related to our acceptance of credit cards as a form of payment, permitted by law. I understand that patient services will only be issued upon receipt of payment for any amount due. I certify that I am an authorized user of this credit/debit card and will not dispute these scheduled transactions with my bank or credit card Company; so long as the transactions correspond to the terms indicated in this authorization form.