New Client Forms - Systematic Healing | Solutions For Optimal Wellness

Credit Card Authorization Form

There are three forms to process. Once you complete this payment form, you will be automatically forwarded to form 2; upon completion, you will be forwarded to form 3 to finish the process.

Please complete all fields. You may modify or cancel this authorization at any time by contacting us at admin@systematichealing.com

This authorization will remain in effect until canceled.

Name as shown on credit card *

First

Last

Credit Card type *

MasterCard
Visa
AMEX
Discover

Credit Card Number *

Layout

Expiration Date (MM/YY) *

CVV 3 or 4 digits *

Billing zip code *

Payment Authorization Agreement *

By checking this box, I authorize Systematic Healing, LLC to charge my credit card above for the agreed upon purchases, including recurring payments for Healing Sessions until paid in full. I certify that I am an authorized user of this card and that I will not dispute the charges with my credit card company, so long as the transaction corresponds to the terms indicated in this Payment Plan Addendum. I understand that my information will be saved to file for future transactions on my account. I understand that this authorization is subject to my Client Agreement and its refund policy.

Signature (use your mouse or finger for mobile) *

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