The undersigned hereby declares that the credit information and name listed in this document is true, accurate. Authorization is hereby given by the above individual to use this card for the purchase of goods and or services from Billing Provider Entity. If this payment authorization is on behalf of another individual, the undersigned authorizes BILLING PROVIDER ENTITY to charge this card for services rendered to the individual specified above (the Service Recipient). If services have been purchased, and a portion or all of this payment is a prepayment for scheduled services, the undersigned hereby acknowledges that this fee is NON-REFUNDABLE once services are rendered. The undersigned acknowledges that no warranty has been given as to the outcome or results of such service and that once services have been RENDERED; fees are non-refundable regardless of outcome, actual results, expected results, or unexpected results. The fee is not subject to the satisfaction (in any way) of the undersigned or the individual receiving services. The undersigned acknowledges that if specific scheduled services are cancelled by the individual receiving services, or by the undersigned or the representative of either the individual receiving services or the undersigned less than two weeks prior to scheduled services, a $1000.00 cancellation fee is charged and is non-refundable.  If the individual scheduled for services does not show for scheduled services without documented notice to an BILLING PROVIDER ENTITY representative, a no-show fee of $2000.00 will be charged and is non-refundable. The undersigned acknowledges that great preparation and effort is made to accommodate, schedule, approve and perform the services scheduled and actually performed. The undersigned acknowledges that any discount provided whether on a pre-payment amount or on the full amount of the fee is at the sole discretion BILLING PROVIDER ENTITY and that such discount is revocable. Any discount is immediately revoked by the undersigned if the undersigned or any authorized representative of the undersigned initiates a “charge back” or any similar action to attempt to refund the fees collected. In addition, a 30% “charge back” assessment will be added to the balance due even if the “charge back” or similar action is unsuccessful and an additional 30% collection fee to the total original and not discounted fees.  I authorize my credit company to accept and to charge my account for these purchases and transactions. If this payment is a partial payment, as per the services and fee agreement I have authorized and signed, or the Service Recipient has authorized and signed, and a balance remains after services are rendered, I authorize BILLING PROVIDER ENTITY to charge my card for any remaining balance after reasonable billing efforts to my insurance have been made by BILLING PROVIDER ENTITY. The determination of reasonable billing efforts will be made at the sole discretion of BILLING PROVIDER ENTITY.  IF I have agreed verbally or Via email or in writing to a payment plan for unpaid balances, those communications become incorporated into this agreement and i authorize the billing srvice provider to charge this card on a recurring basis as per such payment plan authorization. if payment of payment plan fees cannot be collected timely for any reason, the full balance becomes due and owing in full plus all applicable fees and interest and less any discounts. This authorization allows BILLING PROVIDER ENTITY to use this information and such information shall remain in full force and affect unless I revoke such authorization in writing.If the undersigned revokes this authorization, or funds are not available through this card, the UNDERSIGNED WILL BE RESPONSIBLE FOR ANY AND ALL COLLECTION AND ATTORNEY FEES. THE UNDERSIGNED HEREBY AUTHORIZES ANY ATTORNEY AT LAW TO APPEAR IN ANY COURT OF RECORD IN THE UNITED STATES IF THE BALANCE DUE PROVIDED FOR HEREIN IS NOT PAID WHEN DUE, INCLUDING ANY SURCHARGES, FEES, AND INTEREST THEREOF AS PROVIDED HEREIN, AND ON BEHALF OF THE UNDERSIGNED, WAIVES THE ISSUANCE AND SERVICE OF PROCESS, AND CONFESSES A JUDGMENT AGAINST THE UNDERSIGNED IN FAVOR OF THE BILLING PROVIDER ENTITY HEREOF FOR THE AMOUNT OWED ON THE UNDERSIGNED’S ACCOUNT AS MAY BE DUE AND UNPAID HEREON, WITH INTEREST, COSTS OF SUIT, PLUS ATTORNEYS’ FEES OF TWENTY PERCENT (20%), WAIVING ALL EXEMPTION LAWS OF ANY STATE OF THE UNITED STATES (TO THE EXTENT PERMITTED BY LAW), AND RATIFYING ALL THAT SAID ATORNEY MAY HAVE THE AUTHORITY AND POWER TO APPEAR FOR AND ENTER JUDGMENT AGAINST UNDERSIGNED. SUCH AUTHORITY SHALL NOT BE EXHAUSTED BY ONE OR MORE EXERCISES THEREOF, OR BY ANY IMPERFECT EXERCISE THEREOF, AND SHALL NOT BE EXTINGUISHED BY ANY JUDGMENT ENTERED PURSUANT THERETO. SUCH AUTHORITY AND POWER MAY BE EXERCISED ON ONE OR MORE OCCASIONS, FROM TIME TO TIME, IN THE SAME OR DIFFERENT JURISDICTIONS, AS OFTEN AS THE BILLING PROVIDER ENTITY SHALL DEEM NECESSARY OR DESIRABLE. UNDERSIGNED CONSENTS TO THE FILING OF AND MAINTENANCE OF A CONFESSED JUDGMENT ACTION IN ANY COURT OF RECORD IN THE UNITED STATES, EXPRESSLY WAIVES ANY OBJECTION OR DEFENSE AS TO INSUFFICIENCY OF PROCESS, LACK OF PERSONAL JURISDICTION BY ANY SAID COURT OVER THE PERSON, PROPER VENUE, AND SPECIFICALLY CONSENTS TO THE REGISTRATION OR ENROLLMENT OF THE JUDGMENT BY CONFESSION ONCE GRANTED IN ANY OTHER COURT OF RECORD IN THE UNITED STATES. UNDERSIGNED HEREBY EXPRESSLY WAVES ANY RIGHT TO A TRIAL BY JURY IN CONNECTION WITH ANY SUIT BROUGHT BY PROVIDER BILLING ENTITY AS A RESULT OF THIS ACCOUNT