Holistic Treatments and Integrative Medicine Center
Please charge my VISAMasterCardAmerican Express
Card Number
Security Card (found above your name)
Authorized Signature
Exp. Date
Print Name
Address
City
State
Email
Phone
This credit card is to be kept on file and used for only approved charges. Supplements, deductibles and any non covered charges by my insurance company may be charged to this card once I am notified of the amount. Please note that the charges will appear as Patients Medical.
For the Weight Loss Membership program, I will be charged the amount listed of $99 per month on the First of every month until I cancel. Patients Medical may change our prices as described in our Membership agreement. You can cancel any time on one month’s notice.
Date of Charge
For
Amount
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