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.

Phone

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