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Ketamine Media Payment Authorization Form

Thank you for allowing Ketamine Media to be a part of this next stage of growth for your business. Please complete all applicable fields below. If you need to make any adjustments to your preferred method of payment you can do so anytime by contacting us directly at 1-800-975-2291 or As a friendly reminder all credit card transactions will have a 2.7% – 3.9% processing charge applied to your total monthly retainer depending on what your credit card company charges. If you elect to use ACH (debit from your checking or savings account) as your preferred method payment there is no processing fee. 

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