Patient's Name *

First Name

Last Name

Parent/Guardian's Name *

First Name

Last Name

Consent & Agreement *

By submitting this form, I hereby authorize Therapy Trails to charge my credit card for the agreed-upon amount and/or services. I certify that I am an authorized user of this credit card and will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this agreement. Please select "I Agree" below.

I Agree

Acknowledgement of 3% Fee *

I acknowledge that a 3% transaction fee will be added to the total payment amount for using a credit card. This fee covers processing costs incurred by Therapy Trails and will be reflected on my final receipt. By submitting my credit card information, I agree to this additional charge and authorize its inclusion in the total transaction amount. Please select "I Agree" below.

I Agree