Credit Card Authorization

Credit Card Authorization
Teri's Health Services requires a credit card authorization is on record. You authorize your card to be charged for any balances, late cancel fees, or no show fees left unpaid following the service(s). A late cancellation is a cancellation within 24 hours to the appointment and is not rescheduled the same week to bypass the fee. If you need to cancel, please cancel outside the 24 hour mark for the fee to not apply. The fee for a no show or late cancel is $60. A receipt of the transaction will be available upon being charged. If you have questions at any time regarding any charges please email frontdesk@terishealthservices.org or call 602-358-7073.
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Card Holder Name*

First NameLast Name
Relationship to Patient (if patient state patient)*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please take a picture of the front and back of your debit or credit card.
Front of Credit Card*
Back of Credit Card*
Name of Signer*

First NameLast Name
Date of Signature*

MonthDayYear
Date
Signature (authorized credit card on file) *

Clear
Should be Empty: