Credit Card Payment Authorization

Sign and complete this form to authorize the merchant below to make a one-time charge to your Credit Card listed below.

OUM LYMPHATIC requires that you provide your credit or debit card information to keep on file for automatic payment processing of any service charges, including those for late cancellations or missed appointments. It is the client’s responsibility to ensure that card information remains accurate and up to date. All financial information is securely stored in an encrypted, HIPAA-compliant system.

Payment is due at the time of service. If a balance accrues without payment, OUM LYMPHATIC reserves the right to collect the outstanding amount using the card information on file, involve a collection agency, or pursue legal action if necessary. If a balance remains unpaid, we reserve the right to suspend services until payment is received in full or in part.

DISCLAIMER :

By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document.

I *

Authorize Oum Lymphatic to charge my credit card for the amount listed below as payment for rendered services.

Price of service $
On (date)

(input price of package or massage and the date of purchase )_

Services Rendered:

(use drop down to pick massage package)

Email *

Phone *

BILLING DETAILS

Billing Address
City, State
Zip

Card Type

VISA

AMEX

MASTERCARD

DISCOVER

Cardholder's Name
Credit Card Number
CVV
Expiration Date

Outstanding balance (if applicable )

Amount due for outstanding balance

Initial

Signature *

Clear

Date Signed:

For verification purposes, we require a copy of your State ID or Passport to process this transaction. Please provide a clear and legible copy of one of these identification documents. This is to ensure the security of your payment and prevent fraudulent activities. *