Appointment Confimation

Name:
Date of Session:
Time of Session:
No Money is being charged to your card at this time.
Card Type:
Name (as it appears on your card):
Card Number:
Expiration Date:
Security Code (3 on back, Amex: 4 on front):
Appointment Confirmation Code:
***Please Note***



Charles L. Olliff Counseling Services understands that situations arise in which you must cancel your initial appointment.
Therefore, we requested that if you must cancel your appointment, please provide more than 24 hours notice prior to your appointment time.
Charles L. Olliff, M.Ed., LPC reserves the right to bill any office appointments which are canceled with less than 24 hours notification or bill any patient who does not show up for their appointment without a call to cancel an office appointment during the requested time period.
The charge for not attending a scheduled initial appointment or giving a late cancellation within 24 hours of the scheduled date, will be $75.



By submitting the information on this page, I am permitting Charles L. Olliff, M.Ed., LPC to charge my Credit Card if requested notification of cancellation is not submitted in a timely manner.

Thank You for your assistance in this matter.


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