Payment Authorization

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Payment Authorization

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Credit Card Authorization to:
Healing4soul

283 N. Rampart Street #E

Orange, CA 92868

(714) 939 - 9355

Please complete the following information. This information will be kept confidential and used only when charges are incurred for, but not limited to, consultations by telephone, remedies or other products, missed appointment or late cancellation fees.

I hereby authorize Healing4soul to charge my credit card for services rendered, missed appointment or late cancellation fees and/or products provided by the Center in the course of homeopathic consultations. I understand that these charges will be made on the date of service, and I promise to pay all charges in accordance with my credit card company agreement. I understand that fees are due and payable at the time of service, and there are NO REFUNDS for services or products provided by Healing4soul.

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MasterCard

Credit Card #:

Expiration Date (mm/year)

Enter the card's expiration date as month/year

3 Digit Security Code

Name (as it appears on card)

Billing Address

Cancellation Policy:

Appointments that are cancelled 48 hours in advance will not be charged a cancellation fee. Appointments cancelled less than 24 hours in advance will be charged 50% of the scheduled fee.

Aggreement to Cancelation Policy

Cancellation Policy:Appointments that are cancelled 48 hours in advance will not be charged a cancellation fee. Appointments cancelled less than 24 hours in advance will be charged 50% of the scheduled fee.

Yes

No