Recurring Credit Card Authorization Form

Recurring Credit Card Authorization Form
Authorization

I authorize PriorityYou Health Center to charge my credit card for services, treatments, supplements, or memberships as agreed. This authorization will remain in effect until I provide written notice of cancellation.

I understand that:

Charges will appear on my statement under PriorityYou Health Center or its billing partner.
I am responsible for providing updated credit card information if my card expires or is replaced.
Missed or late payments may result in suspension of services until balance is cleared.

Chargeback / Refund Policy
By signing below, I acknowledge and agree that:

I will not initiate a chargeback for services that were rendered or agreed upon.
Any disputes regarding charges must be addressed directly with PriorityYou Health Center.
Refunds are not guaranteed and are at the discretion of the clinic, except as required by law.
Attempting a chargeback in violation of this agreement may result in termination of services and/or collection activity.

Cardholder Agreement
I certify that I am the authorized cardholder and that I have read, understood, and agreed to the terms above.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
By submitting this form, you shall be redirected to PayPal to complete the authorization Process for charging from your account
Signature

Clear
Date

MonthDayYear
Date

PriorityYou Monthly Memberships

Adult Membership Adult Membership 65.00 per month

$65.00 Quantity
Item subtotal:$0.00

Child MembershipChild Membership 35.00 per month

$35.00 Quantity
Item subtotal:$0.00

Hormone Replacement Membership OnlyHormone Replacement Membership Only for Men and Women 25.00 per month

$25.00 Quantity
Item subtotal:$0.00

Total

$0.00