By Checking this box I authorize a (1) one time charge of the amount below to the credit card listed in this authorization form. The payment authorization is for the service of a non-refundable telemedicine membership with a licensed doctor in your state. Your doctor consultations may be reimbursable with your insurance provider. I certify that I’m an authorized user of this card and will not dispute this payment with my card company, so long as the transaction corresponds to the terms and conditions.