Are you ready to make changes now?
Whole Life Scale
Career – 1-10
Health – 1-10
Finances – 1-10
Spirituality – 1-10
Joy – 1-10
Love Life – 1-10
Social Life – 1-10
Relationships – 1-10
Home Environment – 1-10
Service to the world– 1-10
Credit Card Payment Authorization
Sign and complete this form to authorize Dr. Kieran Kuykendall to bill my credit, debit, flex or HSA card listed below.
I, (Full name):*
I authorize Dr. Kieran Kuykendall to charge my credit card as listed below.
Shipping Address (If different than billing address):
This authorization may be revoked at any time when the following stipulations have been performed:
Patient has already made new financial agreement that has been signed and dated or card holder/patient has submitted to our office a written request to revoke the card usage (stop billing credit card in writing signed and dated).
Patient’s account is paid in full.