In the event that you would like to store your credit card information in our secure Square merchant system to pay for therapy, please complete the following fields:
I, as the cardholder, hereby authorize Hope Rising Health Services, LLC to charge my credit card for any copays and balances due for therapy and confirm that the information for the credit card and billing address is complete and accurate.
I further understand that in the event that I fail to cancel my appointment prior to the required 24 hrs notice, or in the event that I do not show for my scheduled appointment, Hope Rising Health Services, LLC will automatically charge my credit card the respective fee as laid out in writing in the Informed Consent for Treatment.
Please type your name below and then sign where indicated to consent to treatment.
If client is a minor, a parent or guardian must sign below to consent to the minor receiving treatment.