I hereby authorize Quinault Wellness Center to initiate a charge entry on my credit or debit card in the amount equal to the amount I enter into the online payment option. I acknowledge I am responsible for inputting the correct payment amount and my Quinault Wellness Center medical record number.

By submitting an online payment, I agree there is a balance sufficient to pay all requested payments and agree Quinault Wellness Center is not liable for any overdraft or insufficient fund situation or similar charges caused by my failure to maintain funds sufficient to pay the amount I indicated.

I understand that I am free to visit my Quinault Wellness Cener to make my payment in person or submit a check to take care of my payment.

I understand that an online payment will be processed and credited to my account within 7-10 business days.