Cardholder Name *

First Name

Last Name

*

I authorize Anna Marie DiPietro, LLC to charge my credit card above for both services rendered as agreed upon in practice office policies as well as for missed/cancelled appointments. I understand that my information will be saved to file for future transactions on my account I understand that this document will serve as proof, should any billing dispute arise, of an agreement of sale for all scheduled appointments that violate the office policy (there are no exceptions). I understand that psychotherapy appointments may be billed either weekly, biweekly, or monthly. Psychiatric appointments are billed at the time of service.