{"id":1784,"date":"2022-03-29T15:16:01","date_gmt":"2022-03-29T15:16:01","guid":{"rendered":"https:\/\/mindspringhealth.com\/payment\/?page_id=1784"},"modified":"2026-08-19T16:37:39","modified_gmt":"2026-08-19T16:37:39","slug":"credit-card","status":"publish","type":"page","link":"https:\/\/mindspringhealth.com\/payment\/credit-card\/","title":{"rendered":"Credit Card"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1784\" class=\"elementor elementor-1784\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3650e23 elementor-section-full_width elementor-section-height-min-height elementor-section-content-middle elementor-reverse-tablet elementor-reverse-mobile elementor-section-height-default elementor-section-items-middle\" data-id=\"3650e23\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-8ac40a2\" data-id=\"8ac40a2\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2453081 elementor-widget elementor-widget-heading\" data-id=\"2453081\" data-element_type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Credit Card Authorization Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-168c03a1 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"168c03a1\" data-element_type=\"section\" data-settings=\"{&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2fe02054\" data-id=\"2fe02054\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-7f4de1af elementor-widget elementor-widget-text-editor\" data-id=\"7f4de1af\" data-element_type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\n<h2 class=\"wp-block-heading\"><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5fcaf3a elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5fcaf3a\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-6d9e26c\" data-id=\"6d9e26c\" data-element_type=\"column\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-958f871 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"958f871\" data-element_type=\"section\" data-settings=\"{&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-a23dd3d\" data-id=\"a23dd3d\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f6d9898 elementor-widget elementor-widget-text-editor\" data-id=\"f6d9898\" data-element_type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"caldera-grid\" id=\"caldera_form_1\" data-cf-ver=\"1.9.7\" data-cf-form-id=\"CF62431abb9dcb4\"><div id=\"caldera_notices_1\" data-spinner=\"https:\/\/mindspringhealth.com\/payment\/wp-admin\/images\/spinner.gif\"><\/div><form data-instance=\"1\" class=\"CF62431abb9dcb4 caldera_forms_form cfajax-trigger\" method=\"POST\" enctype=\"multipart\/form-data\" id=\"CF62431abb9dcb4_1\" data-form-id=\"CF62431abb9dcb4\" aria-label=\"Credit Card\" data-target=\"#caldera_notices_1\" data-template=\"#cfajax_CF62431abb9dcb4-tmpl\" data-cfajax=\"CF62431abb9dcb4\" data-load-element=\"_parent\" data-load-class=\"cf_processing\" data-post-disable=\"0\" data-action=\"cf_process_ajax_submit\" data-request=\"https:\/\/mindspringhealth.com\/payment\/cf-api\/CF62431abb9dcb4\" data-hiderows=\"true\">\r\n<input type=\"hidden\" id=\"_cf_verify_CF62431abb9dcb4\" name=\"_cf_verify\" value=\"77a9fa1d8e\"  data-nonce-time=\"1787324084\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/payment\/wp-json\/wp\/v2\/pages\/1784\" \/><div id=\"cf2-CF62431abb9dcb4_1\"><\/div><input type=\"hidden\" name=\"_cf_frm_id\" value=\"CF62431abb9dcb4\">\r\n<input type=\"hidden\" name=\"_cf_frm_ct\" value=\"1\">\r\n<input type=\"hidden\" name=\"cfajax\" value=\"CF62431abb9dcb4\">\r\n<input type=\"hidden\" name=\"_cf_cr_pst\" value=\"1784\">\r\n<div id=\"CF62431abb9dcb4_1-row-1\"  class=\"row  first_row\"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_3366680\" class=\"form-group\" id=\"fld_3366680_1-wrap\">\r\n\t<label id=\"fld_3366680Label\" for=\"fld_3366680_1\" class=\"control-label\">First Name <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_3366680\" class=\" form-control\" id=\"fld_3366680_1\" name=\"fld_3366680\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_3366680Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_4982765\" class=\"form-group\" id=\"fld_4982765_1-wrap\">\r\n\t<label id=\"fld_4982765Label\" for=\"fld_4982765_1\" class=\"control-label\">Last Name <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_4982765\" class=\" form-control\" id=\"fld_4982765_1\" name=\"fld_4982765\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_4982765Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5877682\" class=\"form-group\" id=\"fld_5877682_1-wrap\">\r\n\t<label id=\"fld_5877682Label\" for=\"fld_5877682_1\" class=\"control-label\">Email <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"email\" data-field=\"fld_5877682\" class=\" form-control\" id=\"fld_5877682_1\" name=\"fld_5877682\" value=\"\" data-type=\"email\" aria-required=\"true\"   aria-labelledby=\"fld_5877682Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF62431abb9dcb4_1-row-2\"  class=\"row \"><div  class=\"col-sm-2  first_col\"><div data-field-wrapper=\"fld_47612\" class=\"form-group\" id=\"fld_47612_1-wrap\">\r\n\t<label id=\"fld_47612Label\" for=\"fld_47612_1\" class=\"control-label\">Zip Code <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_47612\" class=\" form-control\" id=\"fld_47612_1\" name=\"fld_47612\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_47612Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_2020826\" class=\"form-group\" id=\"fld_2020826_1-wrap\">\r\n\t<label id=\"fld_2020826Label\" for=\"fld_2020826_1\" class=\"control-label\">Phone Number <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  data-inputmask=\"'mask': '(999)999-9999'\"  required type=\"phone\" data-field=\"fld_2020826\" class=\" form-control\" id=\"fld_2020826_1\" name=\"fld_2020826\" value=\"\" data-type=\"phone\" aria-required=\"true\"   aria-labelledby=\"fld_2020826Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_613806\" class=\"form-group\" id=\"fld_613806_1-wrap\">\r\n\t<label id=\"fld_613806Label\" for=\"fld_613806_1\" class=\"control-label\">Credit Card Number <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"tel\" data-field=\"fld_613806\" class=\" form-control cf-credit-card \" id=\"fld_613806_1\" name=\"fld_613806\" value=\"\" data-type=\"credit_card_number\" aria-required=\"true\"   aria-labelledby=\"fld_613806Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2 \"><div data-field-wrapper=\"fld_1604471\" class=\"form-group\" id=\"fld_1604471_1-wrap\">\r\n\t<label id=\"fld_1604471Label\" for=\"fld_1604471_1\" class=\"control-label\">Expiration Date <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"  \/  \"  required type=\"tel\" data-field=\"fld_1604471\" class=\" form-control\" id=\"fld_1604471_1\" name=\"fld_1604471\" value=\"\" data-type=\"credit_card_exp\" aria-required=\"true\"   aria-labelledby=\"fld_1604471Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-2  last_col\"><div data-field-wrapper=\"fld_1013844\" class=\"form-group\" id=\"fld_1013844_1-wrap\">\r\n\t<label id=\"fld_1013844Label\" for=\"fld_1013844_1\" class=\"control-label\">CVC <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"credit_card_cvc\" data-field=\"fld_1013844\" class=\" form-control\" id=\"fld_1013844_1\" name=\"fld_1013844\" value=\"\" data-type=\"credit_card_cvc\" aria-required=\"true\"   aria-labelledby=\"fld_1013844Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF62431abb9dcb4_1-row-3\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><p>Credit card on file on is required to confirm all New Patient appointments. Your credit card will NOT be charged until after your scheduled appointment time.<\/p>\n<\/div><\/div><\/div><div id=\"CF62431abb9dcb4_1-row-4\"  class=\"row \"><div  class=\"col-sm-12  single\"><hr id=\"fld_1985355_1\" class=\"\" style=\"width: 100%\" \/><div class=\"\"><p>Cancellation Policy: If an appointment is missed, or canceled within 24 business hours, you will be charged the full session fee.<\/p>\n<\/div><\/div><\/div><div id=\"CF62431abb9dcb4_1-row-5\"  class=\"row \"><div  class=\"col-sm-12  single\"><hr id=\"fld_6794337_1\" class=\"\" style=\"width: 100%\" \/><\/div><\/div><div id=\"CF62431abb9dcb4_1-row-6\"  class=\"row \"><div  class=\"col-sm-1  first_col\"><\/div><div  class=\"col-sm-11  last_col\"><div class=\"\"><ul>\n<li>I have read and agree to the cancellation policy above. <\/li>\n<li>I understand that Mindspring Health Inc. is out of network on my insurance plan and does not bill insurance directly.<\/li>\n<li>I understand I am responsible for payment in full at the time service is rendered, unless other arrangements have been made.<\/li>\n<\/ul>\n<\/div><\/div><\/div><div id=\"CF62431abb9dcb4_1-row-7\"  class=\"row \"><div  class=\"col-sm-12  single\"><hr id=\"fld_8427909_1\" class=\"\" style=\"width: 100%\" \/><\/div><\/div><div id=\"CF62431abb9dcb4_1-row-8\"  class=\"row  last_row\"><div  class=\"col-sm-3  first_col\"><\/div><div  class=\"col-sm-1 \"><\/div><div  class=\"col-sm-3 \"><\/div><div  class=\"col-sm-1 \"><\/div><div  class=\"col-sm-4  last_col\"><div data-field-wrapper=\"fld_7935357\" class=\"form-group\" id=\"fld_7935357_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"submit\" name=\"fld_7935357\" id=\"fld_7935357_1\" value=\"Agree and Submit\" data-field=\"fld_7935357\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_7935357\" id=\"fld_7935357_1_btn\" value=\"\" data-field=\"fld_7935357\"  \/>\n<\/div><\/div><\/form>\r\n<\/div>\r\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Credit Card Authorization Form<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-1784","page","type-page","status-publish","hentry"],"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"Umair Janjua","author_link":"https:\/\/mindspringhealth.com\/payment\/author\/umair\/"},"rttpg_comment":0,"rttpg_category":null,"rttpg_excerpt":"Credit Card Authorization Form","_links":{"self":[{"href":"https:\/\/mindspringhealth.com\/payment\/wp-json\/wp\/v2\/pages\/1784","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mindspringhealth.com\/payment\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mindspringhealth.com\/payment\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mindspringhealth.com\/payment\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/mindspringhealth.com\/payment\/wp-json\/wp\/v2\/comments?post=1784"}],"version-history":[{"count":12,"href":"https:\/\/mindspringhealth.com\/payment\/wp-json\/wp\/v2\/pages\/1784\/revisions"}],"predecessor-version":[{"id":2988,"href":"https:\/\/mindspringhealth.com\/payment\/wp-json\/wp\/v2\/pages\/1784\/revisions\/2988"}],"wp:attachment":[{"href":"https:\/\/mindspringhealth.com\/payment\/wp-json\/wp\/v2\/media?parent=1784"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}