THIRD PARTY CREDIT CARD AUTHORIZATION FORM

download Third Party Credit Card Authorization in .PDF format.

I, __________________________ do hereby authorize IHTI
(Cardholder’s name)

to charge the amount of ______________$ to my credit card on:

(Please circle one): Viza Master Card Discover

Card Number /Payment info: __________________________
Exp. Date _________

This transaction will serve as a prepayment for:
____________________________________

Note: No additional grafts will be performed Procedure

Deposit or_$____________ balance of surgery on __________ (Date)

for__________________________
(Cardholder’s name)

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AND: (will be charged 21 days prior to surgery date)

I, __________________________ do hereby authorize IHTI
(Cardholder’s name)

to charge the amount of ______________$ to my credit card on:

(Please circle one): Viza Master Card Discover

Card Number /Payment info: __________________________
Exp. Date _________

This transaction will serve as a prepayment for:
____________________________________

Note: No additional grafts will be performed Procedure

Deposit or_$____________ balance of surgery on __________ (Date)

for__________________________
(Cardholder’s name)

EXPLANATION OF FIT PREPARATION METHODS:

SHAVEN DONOR AREA - $8g – 500g/750g is the goal per day, but if not achieved, there is no refund. The back of head will be shaved to the scalp – the whole back of head and above ears. If you have prior scarring, it will be visible until hair grows out.

SHAVEN ‘PATCH/STRIP' DONOR AREA - $10g - 500g/750g is the goal per day, but if not achieved, there is no refund. This technique requires Dr. Cole to shave a small ‘patch or strip' in the donor area while pinning the surrounding hair up. Hairs are extracted from this area only, and when the hair is unclipped, it falls down over the donor ‘patch/strip' hiding that area. The disadvantage to this method is that the donor ‘patch/strip' will have less density when it has grown back out, and may be noticeably thinner in that area.

NON-SHAVEN DONOR AREA - $12g - 500g is the goal, but if not achieved, there is no refund.. (This technique requires Dr. Cole to cut one at a time individual follicular units.) Hair will be cut the day prior to surgery because this takes several hours.

BY SIGNING THIS FORM, I AM ACKNOWLEDGING THAT I HAVE READ AND UNDERSTAND THE SHAVEN TECHNIQUES USED, AND THAT I AM SCHEDULED FOR THE PROCEDURE I PREFER AND I AM PAYING FOR THIS PROCEDURE. THE BALANCE IS DUE 21 DAYS BEFORE SURGERY, ON THE 20 ST DAY YOU WILL BE REMOVED FROM DR. COLE'S SURGERY SCHEDULE IF THE BALANCE IS NOT PAID AND PENALTIES WILL BE APPLIED. THE STATE OF GEORGIA AND HIPPA REGULATIONS REQUIRE THAT THIS FORM BE RETURNED WITHIN 24 HOURS OF RECEIPT OR THE APPOINTMENT MAY BE CANCELED.

Please sign and mail, email or fax the completed third party credit card authorization form as soon as possible to: (Please put it to the attention of Michelle Nester.) Fax: 678-566-1957

ADDITIONAL FEES: A mandatory fee of $50.00 has been figured into your balance for Post-operative medications.

Financing available http://www.forhair.com/Hair_Transplant_Cost_and_Financing.htm

Signature of Cardholder Date

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THIRD PARTY CREDIT CARD AUTHORIZATION FORM

AND: (will be charged 21 days prior to surgery date)

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