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WEIGHT MANAGEMENT CC AUTH

CREDIT CARD INFORMATION

By submitting this form, I authorize Progressive Medical to charge my credit card in the amount of $75 in the event that a no-show/late cancellation fee is incurred for my weight management appointment. Appointments should be cancelled by 8:00 a.m. the day prior to the appointment (or by Friday if the appointment is on a Monday). I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds with the terms indicated above.

Type Name of Cardholder
* Required field