Authorization for Credit Card Use
Michael D. McGee, M.D.
Office: 805-459-8232 Cell: 978-360-6071
Fax: 877 399 5883
Board Certified, General Adult Psychiatry, Addiction Psychiatry and Psychosomatic Medicine
6613 B Bay Laurel Place, PO Box 2589, Avila Beach, CA 93424
COMPLETE THIS AUTHORIZATION and click “Submit” on the bottom of the form.
All information will remain confidential and protected.
Name on Card:
Credit Card Type:
Credit Card Number:
Card Identification Number:
I authorize WellMind LLC to charge the amounts listed in my Treatment Agreement for services provided to me during my treatment to the credit card provided herein. I agree to pay for these purchases in accordance with the issuing bank cardholder agreement.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Credit Card Use
Agree & Sign