This professional credit card on file agreement authorizes your practice to securely charge a patient’s card for services, products, late cancellations, and unpaid balances. Ideal for aesthetic, functional, and wellness clinics, the form also includes a HIPAA-compliant privacy disclosure that permits limited release of medical records to resolve payment disputes. Patients agree not to dispute valid charges for services already rendered, and the form includes terms for revocation, privacy, and billing transparency.

Download now to streamline billing, reduce risk of chargebacks, and enforce a clear payment policy with every client.