Credit Card/ACH Authorization Form

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The patient understands there is a charge of $75.00 that will be required for any appointment not cancelled 24 hours in advance.

You may call the office 305-826-6969 or email drglendamartinez@gmail.com in order to cancel. The patient understands that since the appointment has been reserved exclusively for him or her, it is required to cancel or reschedule appointments at least 24 hours to avoid being charged. Insurance company will not pay for missed appointments. You authorize a charge to your credit card for appointments not cancelled within the required 24 hours in advance. A receipt for the charge will be provided to you and will appear on your credit card statement.

I authorize Glenda Martinez (merchant) to charge my credit card. This payment is for the following:

APPOINTMENTS NOT CANCELLED WITHIN 24-HOURS.
Name

Billing

Expiration Date

Contact Me

Scheduling

To schedule an appointment, please call our office at 305.826.6969 or fill out the online form.

We offer both in-person and telehealth sessions.

Location

Our office is conveniently located at 3408 West 84th Street, Suite 302 Hialeah FL 33018.

Within minutes of Miramar, Hialeah, Hialeah Gardens, Miami Lakes, Pembroke Pines, Miami Gardens West. See Driving Directions

Get in Touch

For any other inquiries, you can reach us at gofficephd@gmail.com.

We are here to assist you.