Credit Card Authorization "*" indicates required fields APPOINTMENTS AND CANCELLATIONS Appointments are billed at $150/appointment (50-55 minutes). Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire session fee if cancellation is less than 24 hours. Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE.Client Name Card TypeVisaMastercardDiscoverAmericanName Printed on Card Credit Card Number Exp. Date CVV NumberBilling Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneAuthorization* I authorize Corrine Kisselle LLC to use my credit card information to charge my credit card in the event that I late cancel or do not show for my appointment. I do not dispute charges I receive from sessions I attend, sessions I miss as well as late cancelled sessions. * Signature Type your full name to acknowledge this as your electronic signature.Date MM slash DD slash YYYY Return to All Forms
