Payment Authorization Form

  • (Please enter only the last four digits of your credit card)
  • MM/YY
  • (CCV Code – For Visa, MasterCard, and Discover, this three-digit number is printed on the back of the card, after the card number. For American Express, this four-digit number is printed on the front of the card, above the card number.)
  • I authorize the Institute of Neurological Recovery®, INR PLLC, to charge my credit card listed above in this amount.
    48 business hours (Monday through Friday) notice is required for all appointment cancellations. If appropriate notice of cancellation is not given, the deposit is forfeited.
  • By typing my name in the field above I agree that my electronic signature shall be valid for the purposes of this document.
  • MM slash DD slash YYYY