Credit Card Authorization Form

Email Address

Card Type

Mastercard

Visa

Discover

AMEX

Other

Cardholder Name (as shown on card)

Card Number

Card CVC (What is this?)

Expiration Date (mm/yy)
/

Cardholder Address (from credit card billing address)

Cardholder ZIP Code (from credit card billing address)

I, , authorize Matthew Sachs, MD, MPH, MBA - Child & Adolescent, Adult Psychiatry to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

A concierge, psychiatric practice offering direct access, quick communication, MD-only care, and minimal wait times.
Serving all VA or NC patients - Zoom from anywhere.
We do not take insurance - credit cards are stored w/ encryption.

Text us (encrypted) anytime at 757-219-2753. Fast response.

Follow-ups: $145 for ≤ 15 mins, $175 for ≤ 30 minutes
Intakes: $379 for ≤ 60 min. Longer, more expensive intake options may be required. We CAN diagnose and treat ADHD from scratch.