• Credit Card Authorization Form

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  • Credit Card Information

  • Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

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      Riverview Psychiatric Medicine/TMS Center of the Hudson Valley ServicesCredit Card will not be charged until services are rendered.
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      Credit Card Details
    • I hereby authorize Riverview Psychiatric Medicine, P.C. to keep my signature on file and charge the provided credit card for services rendered.

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