Credit or Debit Card Authorization

ODYSSEY TRAVEL HEALTH, PLLC

Website Credit/Debit Card Policy

Patient Name:   Date of Birth:

Odyssey Travel Health, PLLC (the “Practice”) requires you to provide your credit or debit card information on file with us so we can automatically charge any amounts that you owe for the professional services that we render to you. It is your responsibility to provide the Practice with accurate and updated credit or debit card information. 

Payment is required at the time you book our services.  By signing below, you authorize the Practice to charge the credit or debit card listed below on your behalf for any amounts that you owe to Practice.  Please note that, upon your request, the Practice will provide you with a statement showing the amounts charged to you for services provided and your payments for such services. 

Payment Information:

Circle one: Credit Card    /    Debit Card

Card Type (circle one): Visa  /   Mastercard    /  Discover    /   American Express

Card Number: ____________________________Expiration Date: __________Security Code:_____

Cardholder’s Name:____________________________________________________________________

Your signature below indicates that you, the patient named above, have read and understood this Credit or Debit Card Authorization. Under this Authorization, you are authorizing the Practice to charge the above credit or debit card for ongoing payment toward your balance owed to Practice. You are aware that your information provided in this Authorization will be saved by Practice on file for future transactions on your account.

Patient Signature:   Date:

Questions

If you have any questions or comments about this policy, please contact us using the following contact information:

                           odysseytravelhealth@outlook.com

Date Last Revised: December 15, 2022