Payment Form

Patient Name: *

First NameLast Name

Card Holder Name:*

First NameLast Name

Relationship:*

WE DO NOT CARRY PATIENT BALANCES.
ALL FEES ARE DUE AT THE TIME OF SERVICE.
A VALID CREDIT CARD OR DEBIT CARD IS REQUIRED BY ALL PATIENTS.

In the event of a missed appointment without proper 24 hour cancellation, the following card will be charged for the full fee of the appointment
In the event of a late arrival greater than 10 minutes or a cancellation less than 24 hours, the following card will be charged $100

Please note: You must inform the office if there have been ANY changes to your credit card information. Failure to inform the office of such changes or a declined credit card transaction will result in a $25.00 charge to your account.

By signing below, you agree to, approve, and understand all of the following:

Carolina Complete Psychiatry, PLLC, reserves the right to charge the credit card on file, at any time for service provided by the company and/or if there is a balance on your account.

If your account at Carolina Complete Psychiatry, PLLC carries an outstanding balance for more than 30 days, we may charge the card for the outstanding amount without giving prior notice.

You have the right to request an invoice/statement at any time.

Carolina Complete Psychiatry, LLPC. will not be held liable for any fraudulent charges made to the credit card account.

If you are not the cardholder of the credit card, you agree to take full responsibility for any charges made by Carolina Complete Psychiatry to the card you have provided.

Patient Name:First Name* Last Name*

Date: Date*

Signature*

Payment Method