FORM – Payment Consent

/FORM – Payment Consent
FORM – Payment Consent 2020-04-21T00:40:44-04:00

I authorize Refreshing Waters Counseling & Consulting to charge my credit/debit/health/flex account for Counseling/Coaching Services rendered. I verify that my credit card information provided via the OnPatient Portal is accurate to the best of my knowledge. If this information is expired, incorrect, fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed. In the event of a no show or late cancel fee this card will be charged the session rate of $130 at the time of the missed appointment. By signing below I agree to have the above card automatically charged for any balance due.

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