Credit Card Authorization. Cancellation/No-Show Policy


In an effort to better serve our patients, Advanced Rapid Detox now accepts credit/debit card payments for your convenience. To make payments via credit/debit card, please carefully read, initial, and sign this form.

Please complete all fields. For your security, please ONLY enter the Last 4-Digits of your credit/debit card. We will contact you for your full card number and CVC code. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.

CREDIT/DEBIT CARD AUTHORIZATION

I, , do hereby authorize Advanced Rapid Detox to charge my credit/debit card for payments for services and fees, as outlined below.

INITIAL PAYMENT: (please read and initial)
 I hereby authorize Advanced Rapid Detox to charge my card in the amount of $9,150.00 (less a 2% cash discount if I pay with a debit card). I understand that a 2% Cash Discount is available to me if payment is made by cash, certified check, money order or by debit card. I authorize this payment and agree that I will not dispute this payment at a later date for any reason.

FUTURE PAYMENTS: (please read and initial)
   I hereby authorize Advanced Rapid Detox to charge my card for future services or treatments I authorize.

NO REFUND POLICY: (please read and initial)
   I understand and agree that all medical services are NON-REFUNDABLE.

CANCELLATION/NO-SHOW FEE: (please read and initial)
  I hereby authorize Advanced Rapid Detox to charge my credit/debit card a $500 cancellation/no-show fee for cancellations made or less before an appointment. Further, I authorize Advanced Rapid Detox to charge my credit/debit card a $500 cancellation/no-show fee if I fail to appear for services. Please be advised that cancellations made up to before a scheduled appointment via will be processed without a penalty.  If I reschedule in the future with Advanced Rapid Detox, the $500 cancellation/no-show fee may be credited toward my future treatment. However, I understand and accept that this will solely be at the discretion of Advanced Rapid Detox, and will be determined on a case by case basis.

Type of Card (check one):


Cardholder Name (as shown on card):


Billing Address:


Last 4-Dights of Card Number:


Expiration Date (mm/yy):


Email Address:


By adding my signature below, I certify that I am the cardholder and that I am authorizing this card information be used to process my payment I've provided is I understand that this credit card information is to remain on file with Advanced Rapid Detox until the termination of treatment. All treatment charges will be billed with this credit card unless I request otherwise.

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Signature Certificate
Document name: Credit Card Authorization. Cancellation/No-Show Policy
lock iconUnique Document ID: e0988db5016d8041ff670cb0dfd46c875e2a408e
TimestampAudit
November 14, 2022 5:49 pm ESTCredit Card Authorization. Cancellation/No-Show Policy Uploaded by Suburban Landscape Supply - waivers@suburbanlandscapesupply.com IP 23.126.119.137