Form: Credit/Debit Card Authorization v2 Child NameParent NameCancellation of Services Policy I agree with and understand the Cancellation of Services Policy. CANCELLATION OF SERVICES POLICY – As part of your financial responsibility we are advising you that ASTS INC. reserves the right to charge a fee for any appointment that is not kept or not cancelled by giving 24 hours advanced notice. Currently there is an out of pocket fee of 50% of your total insurance rate for a typical treatment session or a minimum of $55 (effective January 2008), which is subject to change without notice. Unforeseen circumstances are anticipated and will be dealt with on a case by case basis. ASTS, INC has a 3 strike rule. If you are unavailable for a scheduled appointment 3 times without calling to cancel 24 hours in advance of your appointment, ASTS retains the right to discontinue elective treatment and to terminate services immediately. ASTS kindly requests that you offer advanced notification so that your therapist is aware of your need to reschedule. Additionally, at the discretion of ASTS, excessive cancellations within a given month may result in a termination of the given contract. Furthermore, if you plan to dismiss your child from therapy, a 2 week notification is REQUIRED unless otherwise agreed upon. Consequently, if you choose to discontinue treatment you are still responsible for paying for all services that were provided prior to your decision to discontinue.I authorize Advantage Speech Therapy Services to maintain my credit/debit card on file. I understand that this card will only be used if:My child’s account has been delinquent for more than 30 days and I have not made any effort to make payment arrangements.*YESNOMy child’s appointment was canceled with less than 24 hours notice.*($55 or 50% of insurance rate-per policy form)YESNOIt was a no show for a scheduled appointment.*($55 or 50% of insurance rate-per policy form)YESNOI want to set up automatic payments when an invoice is created.*YESNO *There will be a processing fee attached to the use of your card. Date Patient Name:*Cardholder Name:*Cardholder Address:*City:*State:*Zip:*Type of CardVisaMastercardAmexCard#*Expiration:*CVV:*EmailThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.