NEW CLIENT INSTRUCTIONS
WEBPAGE – A
Step 1 – Card Payment Authorization Form
Step 2 – Two “Informed Consents”
Please Mail Originals to Dr. Smith
for Steps 1 & 2 within 24 Hours.
Make copies for your Records
Thank You!
- The date on your first invoice is the date for the Card Payment Authorization Form.
- Please complete all blanks at bottom and at right margin on each document below.
| STEP 1 CARD PAYMENT AUTHORIZATION FORM IMPORTANT READ FIRST Because the processing of your payment for our services does not include swiping your credit or debit card and then signing the payment slip in our presence, our Card Processing Company requires that you complete a Card Payment Authorization Form, which provides written permission for the verbal premission you gave at your appointment to process your card payments. Please note that we do not charge for services or products without your verbal approval first. |
| .. CARD PAYMENT AUTHORIZATION (CPA) FORM Be sure the date on this form is the date of your first paid invoice. | 1 Page |
| STEP 2 TWO INFORMED CONSENTS IMPORTANT READ FIRST “Informed Consent – Clinical Nutrition Program” provides information on what to expect from our Clinical Nutrition Therapy and “Informed Consent – Business Policies” provides some key policy informatoin for all new clients. Other policy information can be found on the “Policies & Procedures” webpage. |
