Financial Form The Forum Financial Form Client Name:(Required) Email:(Required) Contact Number:(Required)Fax Number:Treatment:(Required)SelectIntensive Outpatient - 1 MonthOutpatientCOVID Test - $150OtherAmount(Required) Payment Method(Required)SelectCredit CardCheckWire TransferType of Card:(Required) Personal Card Corporate Card Cardholder Name:(Required) Credit Card Billing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Card Type(Required)VisaMaster CardAmerican ExpressCard Number:(Required) Expiration Date:(Required) CID Number:(Required) (Visa/MC: Last 3 digits located on card back in signature panel, Amex: 4-digit number located on card front right)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Check Number:(Required) Wire Transfer Confirmation Number:(Required) Today's Date: MM slash DD slash YYYY Forum at San Diego BrainWorks Financial Contract for Cost of Treatment All fees are non-negotiable and due and payable at time of admission. By signing this contract as the responsible party for treatment fees. I further understand that all fees paid are non-refundable regardless of length of stay. Deposits and payments are non-refundable & non-transferable. No verbal agreement will supersede this contract. I hereby agree to hold The Forum at San Diego BrainWorks harmless for any and all future claims resulting from this contract. By completing this form you have notified The Forum at San Diego BrainWorks that payment will be made by wire transfer. This form does not process payment from your bank account. Please contact your Bank to initiate wire transfer to The Forum at San Diego BrainWorks.(Required) I have read and agreed to the above Terms and Conditions. I have contacted my credit card provider and placed approval on file for the above submitted The Forum program cost. EmailThis field is for validation purposes and should be left unchanged.