QI ESSENTIALS HEALTH
& WELLNESS CREDIT AUTHORIZATION
PERSONAL AND
CONFIDENTIAL INFORMATION
FIRST
ADDRESS:
_____________________________________________________________
City:
Work PHONE
#:_________________ Home PHONE
#:_________________
Email:
________________________
CREDIT
AUTHORIZATION
I
______________________, hereby authorize Qi Essentials Health & Wellness, to
charge my credit card:
ú
For this transaction only
ú
For all future treatments – an invoice will be provide to
you at each treatment
Credit card
type:
ú
MC
ú
Visa
Credit card
#:________________________
Exp Date:
___/______ 3-4 digit on back of credit
card: ___________
Card Holder
Signature: _______________________________ Date: ________________
Please be
advised that Qi Essentials Health & Wellness has a 48 hour cancellation
policy. Any appointments not cancelled
within 48 hours are subject to a charge of 75% of the service cost. Cancellations can be made via telephone only.
Qi Essentials
Health & Wellness
Tel: 403-616-3256
Fax: 403-630-1275