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Credit Card Authorization

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All appointments need to be cancelled at least 24 business hours in advance and all procedures need to be cancelled 72 business hours or 3 business days in advance. Please note, reminder calls/texts/e-mails are a courtesy. You are responsible for your appointment and Wake Internal Medicine Consultants, Inc. is not liable for any missed reminder phone calls/texts/e-mails.  Please make sure we have your most up-to-date contact information so we can better reach you.

I authorize Wake Internal Medicine Consultants, Inc. to charge my credit card in the event that I fail to show for a scheduled appointment, or do not give notification of my inability to attend a scheduled appointment in advance.  Charges will be as follows:  $50 for an appt and $250 for a procedure.

I further authorize Wake Internal Medicine Consultants, Inc. to disclose information about my attendance/cancellation to my credit card company if I dispute a charge.

This form will be destroyed once your credit card information is entered in our secure practice management system. Please note, your credit card will not be charged unless the following conditions apply: no-show for a scheduled appointment, cancellation of an appointment less than 24 business hours in advance, cancellation of a procedure less than 72 hours in advance, or participation in treatment (e.g. appointment or phone session) without payment rendered.

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