Payment information
By completing this form, you authorize Eagle Crest Wellness to charge your credit card as listed below.
By completing this form, you give permission to debit your account for the amount indicated on or after the indicated date. This is permission for therapeutic treatment fees accrued while in treatment with Eagle Crest Wellness and does not provide authorization for any additional unrelated debits or credits to your account. Credit cards will also be charged in the event that you fail to give adequate notice of missing an appointment. A receipt of credit card processing will be sent to the email provided below up request.