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 card for the agreed-upon amount and/or services. I certify that I am an authorized user of this 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 $2.00 Convenience Fee *

I understand that a flat $2.00 convenience fee will be added to all card and electronic payments. This fee covers processing costs incurred by Therapy Trails and will be reflected on my final receipt. This fee is non-refundable. Cash or check payments do not carry a fee. By submitting my card information, I agree to this additional charge and authorize its inclusion in the total transaction amount. Please select "I Agree" below.

I Agree