I have read and agree to the Terms and Conditions and Privacy Policy
By signing this form, you give us permission to debit your account for the amount of on or after the indicated date. I authorize Artisan chiropractic clinic to charge the credit/debit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the amount of only and is valid for one-time use only. I certify that I am an authorized user of this credit/debit card and that I will not dispute the payment with my credit/debit card company so long as the transaction corresponds to the terms indicated in the form.
