HIPAA Secure Form

Secure Appointment Verification

To secure your appointment slot, we require a validated payment method on file.

There is no charge today ($0.00).

Card Information (No Charge Today)Your card is stored securely. You are NOT charged today.

Card Information

Appointment HoldQuantity-

RTS Appointment – Card on File

1

$0.00

Order Summary

Appointment HoldQuantityAmount

RTS Appointment – Card on File1$ 0.00

Order Total

$

* Your card is encrypted and stored securely. No charge today. *

256-bit SSL Encrypted

PCI Compliant

HIPAA Secure

Your payment information is processed securely. We do not store your full card details on our servers.