30320 Rancho Viejo Rd., Suite 102
San Juan Capistrano, CA 92675
Tel: 949-481-8414
Fax: 949-481-8415
 
Authorization for Credit Card Usage
 
As per office policy, I understand and agree to bear the ultimate financial responsibility for all services rendered by the doctors of CNS. Unless prior arrangements have been made, all appointments cancelled less then 24 hours notice or failure to show for appointments are charged full rate of the reserved time.
I understand and hereby authorize the staff to charge my credit card for any missed appointments and/or any amount not paid by my health plan. [Your account will NOT be charged if neither of the above conditions applies.]
Type of Credit Card:
 
Credit Card Number:
Expiration Date:
First/Last Name on Credit Card:
Name of the Patient:
Billing address of Credit Card:
City:
State:
Zip Code:
Telephone Number:
Signature
 
Step 1: Click Signature to sign this form.
Step 2: Click Finalize to put the signature on this form.
Step 3: Enter the date.
Step 4: Click Submit to send the form.