Patient Payment Form

Patient Payment Form
  • Credit Card Payment Authorization Form

  • Sign and complete this form to authorize Dr. Justin Marchegiani to bill my credit, debit, flex or HSA card listed below.
    Please complete the information below:
  • authorize Dr. Justin Marchegiani to charge my credit card as listed below. Please attach a copy of your insurance card front and back if Dr. Justin has requested it.

  • Date Format: MM slash DD slash YYYY
  • This authorization may be revoked at any time when the following stipulations have been performed:
    1. Patient has already made new financial agreement that has been signed and dated or card holder/patient has submitted to our office a written request to revoke the card usage (stop billing credit card in writing signed and dated).
    2. Patient’s account is paid in full.
The entire contents of this website are based upon the opinions of Dr. Justin Marchegiani unless otherwise noted. Individual articles are based upon the opinions of the respective author, who retains copyright as marked. The information on this website is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Dr. Justin and his community. Dr. Justin encourages you to make your own health care decisions based upon your research and in partnership with a qualified healthcare professional. These statements have not been evaluated by the Food and Drug Administration. Dr. Marchegiani’s products are not intended to diagnose, treat, cure or prevent any disease. If you are pregnant, nursing, taking medication, or have a medical condition, consult your physician before using any products.