THIS AGREEMENT  is made with Carpenter Chiropractic Center, LLC, DBA: Awaken to Wellness Center (herein, “wellness center”), whose address is:  161 St. Matthews Ave Suite 13 Louisville, KY 40207.

I understand that this form is valid until I cancel this authorization through written notice to this wellness center.

 I agree and authorize the card submitted below to be placed on file and used for payment of any Monthly Care Plan Agreements that are currently in place, for payment of any declined post dated payments that are currently outstanding, and to be kept on file and used to pay for any future services I receive at this center.  

You will not be charged for any services that you do not receive.