Credit Card Authorization Form

Download CC Authorization Form

Zen Den offers a secure and convenient method of payment for classes and services, or the portion thereof that is not covered by insurance, but for which you are responsible.

Your credit card information is kept confidential and secure. Charges to your card are processed after services are rendered, or upon a missed class or appointment outside of our cancellation policy. For medical services, charges will be applied to your credit card after the claim has been filed to and processed by your insurance carrier, and the insurance portion of the claim has posted to your account, or, at the time services are rendered in the event valid insurance information was not provided at the time of service.

Here's how it works:

  1. Zen Den Medical Credit Card Authorization Form [Download PDF]
  2. Complete the form and sign it.
  3. Return to Zen Den Medical to be kept on file:
  • Use this secure form to provide your credit card authorization form. Download CC Auth Form Now
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