THER-EX UNLIMITED INC.
37 East 36th Street
New York, NY 10016
CREDIT CARD AGREEMENT
I,, give Ther-Ex Unlimited, Inc. the authorization to charge the below provided credit card for my co-payment as agreed. If my insurance reimburses me for services rendered by Ther-Ex Unlimited, Inc. I am to forward the checks to the corporation. In case that I do not forward checks to Ther-Ex Unlimited they also have the authorization to charge my credit card.
Card Holder’s Name :
Card Type: Visa MasterCard American Express
Credit Card Number:
Expiration Date: /
Card Holder’s Signature:
I agree and understand the terms and condition that apply
Signature XPRINT
Office Policies
Patient consent
New Patient Registration Form
credit card authorization