By your electronic signature of this form, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement as [STATEMENT DESCRIPTOR]. You have the right to request a paper copy of this document.

I authorize Lean Leaf LLC to charge my credit card through Stripe. I also agree that my credit card can be charged on a monthly recurring basis until the policy is cancelled.

I understand that this authorization will remain in effect until I cancel it in writing by contacting them at joinleanleaf@gmail.com, the messaging center in the patient portal, or cancelling it using my login to enter my account on the platform or app, and I agree to notify Lean Leaf in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.