Credit Card Authorization Form

Credit Card Authorization Declaration Form

Please complete this form to authorize credit card payments.
Full Name on Card*

First NameLast Name
Billing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Credit Card Type*
Credit Card Number Last 4 Digits*
Authorization Statement*
I authorize PriorityYou Health Center, LLC to charge the debit/credit card listed above for the agreed upon purchases listed on or after the date list below. This is permission for a single transaction, per item, unless otherwise agreed upon, and does not provide authorization for any additional unrelated debits or credits to your account. By completing and signing this form, I acknowledge that the charges, once charged, are non-refundable. I certify that I am an authorized user of this debit/credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this form.
Signature*
Should be Empty:

Credit Card Authorization Declaration Form