Client Massage Intake Form (Page 3 of 3) in pdf

Credit Card Authorization Form

(Mandatory for all patients)

Patient Name:

Date of Birth:

The purpose of this form is to authorize RunLab to retain a valid credit card number on file for you as our patient. All

patients are required to complete this form. This form will be kept confidential and only authorized staff will have access

to the information. Your supplied credit card will be charged ONLY under the following circumstances:

1. Kimberly Mullen, DC, PLLC dba Back At It Sports Performance reserves the right to charge the credit card listed below

weekly for all current patient balances under $250.00, including co-pays, deductibles, coinsurance and charges not covered

by your insurance provider. A credit card receipt or itemized receipt is available on request. This notice serves as your

consent to being charged for all current patient balances under $250.00 on your account. A representative from RunLab

will contact you regarding balances over $250.00.

2. We value the time we have set aside to see and treat you. If you are not able to keep an appointment, we require 24

hours notice. There is a charge of $95 for late cancellations and no-shows. As a courtesy, a representative from RunLab will

call the phone number on file to remind you of your scheduled appointment. It is the patient’s responsibility to ensure we

have a correct, current telephone number on file. RunLab reserves the right to charge the credit card listed below $95 for

our standard no-show fee. A receipt is available on request.

3. If we receive notice that a payment is returned to us for any reason, RunLab reserves the right to charge a $25 processing

fee. You will have 10 business days to provide us with adequate payment method before your account is referred to

collections. This notice serves as your consent to being charged for any returned payments.

Other than the conditions mentioned above, under NO circumstance would RunLab charge your credit card for anything

not discussed personally with you. In conjunction with HIPAA regulations, all credit card information will be confidentially

and securely stored via Transfirst Merchant Services. Only authorized staff will be able to access this information.

Acknowledged, Agreed & Accepted:

Having read this form and talked with the staff, my signature below acknowledges that I voluntarily give my

authorization and consent to providing the requested information for my credit card to be charged accordingly for the

conditions listed above.

Patient (Guardian) Signature

Date

Staff Signature

Date

Name As It Appears On Credit Card:

Billing Address:

AMEX / DISC / VISA / MC Number:

Expiration Date:

Verification Code (3 Or 4 Digits):

Credit Card Authorization Form

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Client Massage Intake Form Page 3