Champion Health and Wellness Clinics

4295 San Felipe St., Ste. 235 Houston TX 77027
281-501-0611

Patient Consent Form

Tirzepatide Onboarding Process

step 4

80%

"*" indicates required fields

CREDIT CARD AUTHORIZATION FORM

I authorize Champion Health and Wellness Clinics to process the credit card on file for any non refundable booking fees, no show fees, visit charges, or balance due on my account and for any payments authorized by me.

I understand that a receipt superbill showing what was paid for will be promptly sent to me upon any payments made using the card on file.

I understand that I am responsible for notifying the clinic if anything changes in my credit card information.

Name*