Recurring Membership Payment Authorization Form

We are excited to serve all of your health and wellness needs! Dr. Dalton would like to thank you for becoming a member and trusting him with your care and the care of your loved ones!

Sign and complete this form to authorize Lubbock Integrative Medical Associates to make a recurring monthly credit card payment for the membership fee. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a recurring membership fee and does not provide authorization for any additional unrelated debits or credits to your account.

I (person named in contact from below) authorize Dr. Dalton to charge via bank draft or credit card to my account indicated below for membership services indicated in the form below recurring monthly by date provided. (if not specified, the date this is signed will be your charge date) * If I with to use the Bank Draft Option I will call the LIMA office and set it up over the phone!