TEST - Lora Sant, Marriage and Family Therapy

* Indicates required field

Name *

First

Last

PAYMENT AGREEMENT *

I/We agree agree to pay $100 to Lora Sant for a 60 minute session at the time of the session.

MISSED APPOINTMENT FEE *

I/We understand that missed appointments or appointments that are cancelled with less than 48 hour notice will be charged to credit card at agreed upon session fee.

CREDIT CHARGE *

I/We authorize Lora Sant to retain my/our credit card information on file and charge my/our credit card for services as rendered. (Discounted services must be paid with cash or check.)

CREDIT CARD # *

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