Payment Authorization Form

Patient Name*
First Name Last Name
Name On Credit Card*
First Name Last Name
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card Type*
- Visa
- MasterCard
- Discover
- American Express
Last 4 digits of your Credit Card number*

(Please enter only the last four digits of your credit card)
Expiration Date*

MM/YY
CCV Code*
(CCV Code – For Visa, MasterCard, and Discover, this three-digit number is printed on the back of the card, after the card number. For American Express, this four-digit number is printed on the front of the card, above the card number.)
Amount:*
I authorize the Institute of Neurological Recovery®, INR PLLC, to charge my credit card listed above in this amount.
Cancellation Policy:*
- I understand and agree to the Cancellation Policy
48 business hours (Monday through Friday) notice is required for all appointment cancellations. If appropriate notice of cancellation is not given, the deposit is forfeited.
Please check one of the following:*
- I am the patient and cardholder, and I agree to be fully responsible for this charge.
- I am the cardholder, and I agree to be fully responsible for this charge incurred by the patient listed above.
Authorization Name*
First Name Last Name
By typing my name in the field above I agree that my electronic signature shall be valid for the purposes of this document.
Date*
MM slash DD slash YYYY