Payment Authorization

Payment Authorization

By Checking this box I authorize A (1) one time charge of $24.99 to the credit card listed in this authorization form. The payment authorization is for the service of a (1) time telemedicine

consultation with a doctor licensed in the state in which I reside and in the amount attached to this authorization form. I certify that I am an authorized user of this card and will not dispute this payment with my card company, so long as the transaction corresponds terms indicated in this form.


Or


By Checking this box I authorize A (1) one time charge of $39.99 to the credit card listed in this

authorization form. The payment authorization is for the service of a (1) time telemedicine

consultation with a doctor licensed in the state in which I reside and in the amount attached to this authorization form. I certify that I am an authorized user of this card and will not dispute this payment with my card company, so long as the transaction corresponds terms indicated in this form.