APEX CHILD, ADOLESCENT & ADULT PSYCHIATRY, P.A.
ANNE-MARIE TURNIER, M.D
108B N. SALEM STREET ♦ SUITE 203
APEX ♦ NORTH CAROLINA 27502
(919) 632-2803 ♦ FAX (919) 363-9927
AUTHORIZATION FOR CREDIT CARD USE
I, ______________________________, here by authorize Apex Child, Adolescent &
Adult Psychiatry, P.A. to charge my credit card for all related charges to the treatment of
______________________________. I understand that these charges will consist of fees
for office based visits, extended phone conversations, and missed appointments/late
cancellation fees.
INFORMATION ON MY CARD:
Name on card:_______________________________________
Number: ____________________________________________
MasterCard/Visa
Expiration date:____________________
I will receive an invoice for the visit either from the patient who attended/participated in
the visit or will ask for the invoice to be mailed to myself for an additional charge of
$1.00. I may also arrange with ACAAP, P.A. other reasonable method to acquire the
invoice.
___________________________________
Signature
___________________________________
Printed name