By completing this form, I authorize The Moment to charge this credit card for the cost of treatment and any ancillary expenses pertaining to the patient named below, with the understanding that there is a 24-hour change/cancellation policy (Monday appointments must be changed/cancelled on Fridays, 24 hours prior), and that missed/late cancelled appointments will be charged at the usual rate. I understand that all charges will appear on my credit card statement as Stacy A Cohen, MD CORP.

I understand that I can revoke or change this authorization (to the extent that it has not already been relied upon) by delivering a written statement to The Moment.