credit card authorization
pet loss dc
Jessica Kwerel, LPC, LCPC
petlossdc.com
jessica@petlossdc.com
(202) 642-2682
By signing below, you agree that the credit card information you provide will be kept on file and charged for any balances related to your account (i.e., session fees, late cancellation fees, etc.). Credit card information is stored securely using the payment processor, Stripe, which requires a multi-factor authentication.
In addition, your signature implies your consent for Jessica Kwerel, LPC, LCPC of Pet Loss DC to store your credit card and charge your credit card without you being present. Further, by signing
below, you acknowledge that you are aware that your credit card statement will reflect a charge from Jessica Kwerel of Pet Loss DC.
In the event that you miss an appointment or cancel an appointment without providing 24 hours notice, or you need to reschedule an appointment without providing 24 hours notice, you will be held responsible for a missed appointment/late cancellation fee. With this form, you acknowledge that you are aware
of this policy as stated in the Disclosure and Informed Consent Statement.
You understand that this authorization will remain in place until Jessica Kwerel, LPC, LCPC of Pet Loss DC has received written notification from you of its termination. You also understand that it is your responsibility to provide updated information if anything below should change (i.e., card expiration)
esignature
Per the ESIGN Act, your esignature is legally binding. By signing your name electronically below, you are agreeing that your electronic signature (or esignature) is the legal equivalent of your manual signature.