CREDIT CARD AUTHORIZATION

Credit Card Authorization Form

"*" indicates required fields

Type of Card:*

Personal Card

Corporate Card

Client Name:*

Email Address:*

Daytime Telephone:*

Fax Number:

Treatment:*

Amount*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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

This field is for validation purposes and should be left unchanged.

2750 S Harbor Blvd, #G, Santa Ana, CA 92704