CC + Insurance

Credit Card Info
Patient's name*

First NameLast Name
Card holder's name*

First NameLast Name
Upload a photo of your credit card (showing full number)*

Cancelof
Upload a photo of your credit card*
Security code*
Signature*

Clear
The above-signed authorizes Vitality Health & Wellness, LLC to keep their signature and credit card information on file in a digitally secure password protected file and to charge their credit card for all charges incurred by them for themselves or the patient that they are authorizing their credit card on behalf of. as per the policy described on this form and the patient registration form.
Insurance Card Info
Upload a photo of the front of your insurance card
Upload a photo of the back of your insurance card
Should be Empty:

Credit Card Info