Authorization to Secure Payment

Please Enter The Cardholder's Full Name

Please Enter The Patient's Full Name

Please enter a Valid E-mail Address

Please enter a Valid Credit Card Account Number

Please Enter a Valid Date Example: xx/xx

Please enter a valid CCV. This number is printed on your cards in the signature area of the back of the card.

Please make a selection.

Please make a selection.

Please make a selection.

You must check the box in order to proceed.

  • The above mentioned charges on your card will appear from CLAY Therapeutic Services
  • If the credit card  is a flexible spending card, charges may not go through.  In such cases, we will contact you to determine other payment options
  • All missed appointment fees will be charged at $145 a missed appointment.
Please Enter your Full Name. This will serve as your digital signature.

Please Enter a Valid Date of Birth

Please Enter Today's Date

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