Credit Card Authority Form

Type of client *

New Client
Existing Client

Personal Details

First Name *

Family Name *

Email *

Card Details

Visa/Mastercard

Card Holder Name *

As shown on card

Card Number *

Expiry Date *

As shown on card

CVN *

Your Authority

I understand my credit card will be charged upon booking my first appointment if a new client or on the day of my scheduled appointment if an existing client *

I understand my credit card will be charged upon booking my first appointment AND on the day of my scheduled appointment

A booking fee of $100 will be charged upon booking and this amount will be deducted from the total fee of your appointment

I understand my credit card will be charged on the day of my scheduled appointment *

I understand my credit card will be charged on the day of my scheduled appointment

I understand my credit card will be charged FULL FEE if late cancel / no show as per PsychSolutions Credit Card Management Policy *

I understand my credit card will be charged FULL FEE if late cancel / no show as per PsychSolutions Credit Card Management Policy

Please read and understand our Payment Terms Policy and our Credit Card Management Policy

I authorise PsychSolutions to securely store and charge my credit card. *

I authorise PsychSolutions to securely store and charge my credit card.

Signature *

Date *

Personal Details

Card Details

Your Authority

Orange

Dubbo

Bathurst