iMind - Credit Card Authorization Form

Sep 17, 2026

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This Credit Card Authorization Form for iMind Mental Health and Wellness LLC serves as a formal mandate for patients to maintain payment information on file. The document outlines the necessity of securing credit card details, including card type, number, expiration date, and billing ZIP code. It explicitly defines a financial policy regarding appointment attendance, authorizing a $100.00 charge for late cancellations made without 24 hours' notice or for missed initial appointments. By signing this agreement, the client consents to have their payment information securely stored for future transactions, streamlining the billing process for professional mental health services. This form ensures operational efficiency for the wellness center while clearly communicating fiscal responsibilities to all patients, thereby minimizing administrative friction during the checkout or scheduling phases.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Credit Card Authorization Form

Credit Card Information

Authorization and Policy Terms

FAQs

What happens if I miss my appointment or cancel late?

If you fail to provide at least 24 hours' notice for a cancellation or do not show up for your initial appointment, your credit card on file will be charged $100.00.

What information is required on the card form?

You must provide the card type (MasterCard, VISA, Discover, AMEX, or Other), cardholder name, card number, security code, expiration date, and the billing ZIP code.

Why does the practice require a card on file?

iMind requires a card on file for all patients to facilitate future transactions and ensure adherence to the appointment cancellation and no-show policy.

Sep 17, 2026

Upload by Marry