VANITY Payment Authorization Form

VANITY Payment Authorization Form

Authorize secure one-time or recurring payments. Your information will be kept confidential and handled in accordance with security regulations. 2026-2027
Customer Information

Please provide your details as they appear on your billing records.
Full Name*

First NameLast Name
Company Name (optional)
Billing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Payment Details

Please specify the type and details of your payment authorization.
Type of Authorization*

One-time payment $250 for a virtual consultationRecurring payments for scheduled appointments.Full payment is processed two hours before the appointment starts. Cancellations must be made within 24 hours. Client responsible for full payment if cancellation is less than 24 hours.
Start Date | After Jan 1, 2026*

MonthDayYear
Date
Continue recurring payments until canceled*

Until canceled
Description of Goods/Services*
Cardholder Information

Provide cardholder details as they appear on your payment card. (Sensitive card data is not collected via this form.)
Name on Card*
Card Type*
Billing ZIP/Postal Code*
Authorization & Consent

Please review the authorization statement below and provide your consent.
I authorize Vanity Hair Studio NYC to charge my payment method for the amount(s) specified above. I understand this authorization remains in effect until the end date specified or until I notify Vanity Hair Studio NYC in writing to cancel, allowing reasonable time to act. I certify I am an authorized user and will not dispute payments provided transactions correspond to this authorization.
I have read and agree to the authorization statement above.*

I agree
Signature & Confirmation

Sign below to complete your authorization.
Electronic Signature*

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Printed Name*
Date*

MonthDayYear
Date
Security & Compliance Notes

Sensitive payment data is never collected via this form. Your authorization will be kept on file securely for the duration required by law or business policy.
Internal Notes (for business use only)
Send me a copy of this authorization by email.

Send me a copy by email
Should be Empty:

VANITY Payment Authorization Form

Customer Information

Payment Details

Cardholder Information

Authorization & Consent

Signature & Confirmation

Security & Compliance Notes