Credit Card Payment Agreement

Credit Card Payment Agreement

Credit Card Authorization

By submitting this form, you agree to allow U Are Heard, LLC to charge your credit card for the sole purpose of payment for any of the following: Coaching Session, Counseling Session, Family Consultation, Administrative fees (missed appts., etc).


















By submitting this form, you are permitting U Are Heard, LLC to submit charged through the credit card listed and you understand a service fee of $3 will be applied. You also understand that you can also obtain a separate receipt (superbill) for insurance purposes upon request. You also understand that this document will remain part of your medical/billing record until you request that it be removed.

Quantity Description Price
1 Credit Card Authorization $0.01

Address

302 West Main St.
Avon, CT 06001

Phone

860-214-7583

Email

info@uareheard.com