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You are agreeing to pay $ plus a Fee of $ (%) for a Total of $.

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I authorize Muenster Family Health Clinic to process the above payment of $. I also authorize Muenster Family Health Clinic to store this information in compliance with payment processing regulations and to charge the card listed above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact Muenster Family Health Clinic prior to the payment date.

I authorize Muenster Family Health Clinic to process the payments as outlined in the payment schedule. I also authorize Muenster Family Health Clinic to store this information in compliance with payment processing regulations and to charge the card above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact Muenster Family Health Clinic prior to the payment date.

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