Credit Card Authorization Form

Our online payment option is under construction. Please call to pay by credit card 866-746-1558

"*" indicates required fields

Type of Card:*

Personal Card

Corporate Card

Client Name:*

Email Address:*

Daytime Telephone:*

Fax Number:

Treatment:*

Amount*

Billing Address*

Credit Card*

Card Details

Cardholder Name

Today's Date:

All fees are non-negotiable and due and payable at time of admission.
By signing this contract as the responsible party for treatment fees. I further understand that all fees paid are non-refundable regardless of length of stay.
Deposits and payments are non-refundable & non-transferable.
No verbal agreement will supersede this contract.
I hereby agree to hold Rising Roads harmless for any and all future claims resulting from this contract.

Costs of Treatment Contract*

I have read and agreed to the above Terms and Conditions.

I have contacted my credit card provider and placed approval on file for the above submitted Rising Roads program cost.

Name

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