Credit Card Authorization Form

1

2

Cardholder Name

First Name

Last Name

3

Credit Card Number

Please enter a number

4

Expiration Date

5

CVV/CVC

6

Issuer

VISA

Master Card

AMEX

Discover

7

Total Amount to be Processed

8

I hereby acknowledge that the information contained in this form, including contact information, medical history, and diagnosis, is correct as of the time of signing. I understand that it is my responsibility to report changes in information, history and diagnosis at least 5 business days prior to my appointment. I hereby acknowledge that no guarantees have been made and that the practice of regenerative therapy is not an exact science and that the therapy may involve risks. I acknowledge that this procedure is considered elective and not medically necessary. No outcome may be the result of the therapy. I hereby acknowledge that no employees or contractors of Regen Bioscience are to be considered my primary care provider and that the care provided is limited to the areas listed above in this agreement.

I agree

9

I hereby acknowledge that this therapy can be rescinded, for a full refund, within 3 business days of signing this agreement. Refunds will be sent within 10 days. I hereby acknowledge that this therapy can be canceled up to 7 business days prior to the scheduled appointment in writing. If this is the case, my refund will be processed within 30 days of receiving cancellation request. I understand that if I cancel within 7 business days of my appointment, I will be responsible for the cost of materials and other costs associated with the late notice cancel. I hereby acknowledge that if 12 months following therapy, I am not at least 50% improved in the area therapy was administered and have followed the protocols given to me for my success, Regen Bioscience will provide an additional therapy session at an 80% discount. I hereby acknowledge that this agreement goes into effect when Regen Bioscience receives payment. I agree and understand that this agreement constitutes the entire understanding between the parties, and that there are no verbal understandings changing or modifying any of the terms of this agreement.

I agree

10

I hereby agree to receive calls, text messages and emails from Regen Bioscience. Regen Bioscience products are not FDA approved or licensed for the prevention, treatment, diagnosis, mitigation and/or cure of any disease or condition. I, as a cardholder, hereby authorize InitiateU, Inc DBA Regen BioScience to charge my credit card for {conditiontext} and confirm that the information for the credit card and billing address is complete and accurate.

I agree

11

Date

12

Cardholder Signature

Powered by Jotform SignClear