CREDIT CARD AUTHORIZATION

This form authorizes charges for services rendered through Ascension Hypnotherapy & Wellness. Your card will only be charged after services are provided or in accordance with the cancellation policy outlined in the Service Agreement.

By signing below, I agree that:

• I authorize charges for any session I attend or miss without 24 hours notice (cancellation fee: $180)
• This authorization remains valid until I revoke it in writing
• I have read and understand the financial and service policies provided

Signature: ____________________________      Date: ____________

Cardholder Name (Printed): ____________________________