Credit Card Authorization

Card Type
Please Check One
Untitled*
- VISA®
- American Express®
- MasterCard®
- Discover®Card
Billing Information
Cardholder Name:*
Billing Address*
City*
State*
Zip*
Credit Card Information
Credit Card Number*
CVV*
Expiration Date
Client Info
Client Name*
Date of Birth:*
MM slash DD slash YYYY
Consent*
I authorize Iris Healing® Retreat, LLC to charge my credit card listed below for:*
Consent*
Check in this box to authorize pharmacy co-pays to be charged to the card below*
Consent*
Check this box to approve ancillary expenses to be charged to the card below. This includes transportation to/from the facility ,cigarettes , and any other elective purchases. If you would like to set a limit on how much can be spent on ancillary charges please enter that amount on the line below*
Ancillary spending limit:*
In the event you wish to change the credit card authorized herein to be charged, Iris Healing® Retreat requires notice of the desired change in writing, dated, and including the language set forth herein and all necessary card information, as well as the date on which the desired change shall be effective, and the cardholder’s signature. Cardholder agrees to update Iris Healing® Retreat with a new authorization prior to the expiration date of the card authorized herein to be charged, in order to ensure payments may be charged prior to services being rendered. I have the right to change or terminate this authorization at any time but must do so in writing via email to Info@IrisHealingRetreat.com The termination of this authorization shall be effective 24 hours after we receive the termination notice.

I, the undersigned, understand that all financial payments are considered final sale and are non-refundable.
Statement Email Address*
Cardholder Signature*
Contact Name*
Phone Number*
Date*
MM slash DD slash YYYY

Have Question?

Visit Us

IRIS HEALING® RETREAT
Credit Card Authorization Form

Card Type

Billing Information

Credit Card Information

Client Info

About Us

Treatment

Our Locations

Have Question?

Visit Us

IRIS HEALING® RETREAT Credit Card Authorization Form

Card Type

Billing Information

Credit Card Information

Client Info

About Us

Treatment

Our Locations

IRIS HEALING® RETREAT
Credit Card Authorization Form