(Please fill out all the fields) (Form: psycinitial)
We want to make sure you are aware that:
By completing this part you hereby authorize Brighton Health Clinic for Kids to debit your bank account or credit card shared below, for each session on the day of consultation. This is permission for the amount to be charged as per our fees described above. Any additional costs for extended sessions or further assessments cannot be charged without confirmation from the client. This authorization does not provide authorization for any additional unrelated debits or credits to your account.
We take automatic payment on the day of consultation and a receipt is issued via email. All credit card payments will incur a surcharge of 1.010% during processing. Kindly note that declined cards may result in an additional processing fee as it will go through an additional process when the attempted card is charged again. You authorize the above named business to charge your bank account or credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the services described above, for the session cost only. You certify and confirm that you are an authorized user of this bank account or credit card.
** Supplementary Consent Information - please click here to read (pdf file)