AGErite Secure HIPAA-Compliant Payment Information Form (Clinics)

Secure-HIPAA Compliant Payment Information Form

12827 Telge Rd Ste 160, Cypress, TX 77429 Phone (281) 654-8417, Fax (281) 605-1912 compounding@AGEritePharmacy.com www.AGEritePharmacy.com
Clinic Information
Clinic Name
Cardholder Information
Cardholder Name

First NameLast Name
Cardholder Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email for submission confirmation
example@example.com
Cardholder Information
Credit Card Number (4 digits per line max)
CVC
Expiration Date
Would you like AGErite to keep this card on file for future orders?
*I certify that the payment and card information are correct and authorize AGErite to use this card for my transaction*

I authorize AGErite Pharmacy LLC dba AGErite Pharmacy & Wellness Center to charge my credit card on file based on clinic billing that I signed up for. This authorization will remain in effect until I cancel it. I may cancel this authorization any time by contacting AGErite Pharmacy at (281) 654-8417 or emailing info@AGEritePharmacy.com.
Cardholder Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Secure-HIPAA Compliant Payment Information Form