Payment Authorization-OLD
  1. Patient Name(*)
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  2. Email Address(*)
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  3. Date of Birth(*)
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  4. Please complete the following information. This information will be kept confidential and used only when charges are incurred.

    I hereby authorize Healing4soul to charge my credit card for services rendered, missed appointment or late cancellation fees and/or products provided by the Center in the course of my treatment. I promise to pay all charges in accordance with my credit card company agreement.

    I understand that there are NO REFUNDS for services or products provided by Healing4soul.or Sima Ash Wellness Center

  5. Payment Authorization for:(*)






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  6. Credit Card(*)



    Invalid Input
  7. Credit Card Number(*)
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  8. 3 Digit Security Code(*)
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  9. Expiration Date (Month/Year)(*)
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  10. Name (as it appears on card)(*)
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  11. Billing Address (*)
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  12. Verification(*)
    Verification
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