Agreement to Securely Storing Credit Card Details

We believe in transparency and want you to understand exactly how our financial arrangements work. This form outlines our policies around storing Credit Card Details so you can make informed decisions about your care. What is written here is the equivalent of the paper form available to you, and  is accepted by the questions on our consent form.

STORING YOUR PAYMENT DETAILS SECURELY

To make payment easier for you, we offer the option to securely store your credit or debit card details.

How We Store Your Card Details

• We use Stripe (Attuned)  and Braintree/Paypal (Adelaide Night and Day Occupational Therapy),both PCI-DSS Level 1 certified payment processor (the highest level of security in the payment industry.) 
• Your card details are encrypted and stored securely.
• We never see or have access to your complete card number
• Your card details are used only for processing payments for services you receive at the practice

For More Information of Praintreee/Paypal https://blog.halaxy.com/halaxy-card-security-faqs/

For more information on Stripe https://support.stripe.com/questions/faq-for-customers-of-businesses-using-stripe

Your Rights Regarding Stored Card Details

You have the right to:

• Request that your stored card details be deleted at any time
• Update your card details if they change
• Receive confirmation that your details have been securely stored

To request deletion or updates, simply contact our practice administrator.

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YOUR QUESTIONS AND CONCERNS

If you have any questions about:

• Our fees or payment options
• Your account or invoices
• Financial arrangements
• This information form

Please don’t hesitate to ask. We’re here to help make this process as clear and stress-free as possible.

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CLIENT DETAILS

Full Name: _______________________________________________________

Date of Birth: _____ / _____ / _________

Address: ________________________________________________________

Email: __________________________________________________________

Phone: __________________________________________________________

Client Signature: ________________________________ Date: _____ / _____ / _____

(Or parent/guardian signature if client is under 18)

Print Name: _______________________________________

If signed by parent/guardian:

Relationship to client: _________________________________

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YOUR CONSENT AND AGREEMENT

(When you agree in the client consent form, you are agreeing to the following)

By signing below, I acknowledge that:

☐ I have read and understood this Agreement to Securely Storing Credit Card Details

☐ I have had the opportunity to ask questions and have received satisfactory answers

☐ I understand the fees for therapeutic services at the practice

☐ I understand the payment methods available and when payment is due

☐ I understand the cancellation policy and that fees may apply for late cancellations or missed appointments

☐ I understand the process for managing overdue accounts

☐ I understand how my financial information will be stored and protected

☐ I agree to these financial arrangements and payment policies

☐ I understand I can request a copy of this form for my records

REGARDING CREDIT CARD STORAGE (circle yes or no)

I give consent for the practice to securely store my Credit Card Details Yes/No

Do you authorise the practice to use Stored Credit Card Details for any payments without contacting you first? Yes/No

Do you authorise The practice to use Stored Credit Card Details for payment of Telehealth (video/phone) Appointments and/or for services for which prepayment is sought, within 24 hours of a request for payment Yes/No 

For any Accounts which remain unpaid, do you authorise the practice to use Stored Credit Card Details, within 24 hours of a request for payment being sought? Yes/No

If you consent to card storage, please complete:

Cardholder Name: _________________________________________________

Card Type:  ☐ Visa  ☐ Mastercard  ☐ American Express

Last 4 digits of card: ____ ____ ____ ________ [On Online Form – Full Number is required]

Expiry Date: _____ / _____

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PRACTICE USE ONLY

Received by: _____________________________________ Date: _____ / _____ / _____

Card details securely stored  ☐ Yes  ☐ No  ☐ N/A

Client provided with copy of form:  ☐ Yes

Filed in client record:  ☐ Yes

THE PAPER COPY WILL BE DESTROYED AFTER ENTERING responses

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This form complies with:

• Australian Privacy Principles (Privacy Act 1988)
• Psychology Board of Australia Code of Conduct for Psychologists
• Health Practitioner Regulation National Law

Version: 1/1/2026

Review Date:1/1/2027