Are you ready to make changes now?
YesNo

Whole Life Scale

Career – 1-10
12345678910

Health – 1-10
12345678910

Physical Activity

Finances – 1-10
12345678910

Spirituality – 1-10
12345678910

Joy – 1-10
12345678910

Love Life – 1-10
12345678910

Social Life – 1-10
12345678910

Relationships – 1-10
12345678910

Creativity 1-10
12345678910

Home Environment – 1-10
12345678910

Service to the world– 1-10
12345678910

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.

Billing Address:

Shipping Address (If different than billing address):

Account Type:*
VisaMasterCardFlex/HSADiscover

Cardholder Name:*

Account Number:

Exp Month:*

Exp Year:*

CVC*

SIGNATURE:*

DATE:*

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.