Credit Card Authorization Form

Credit Card Authorization Form

  • Please enter a number less than or equal to 9999.
  • mm/yy
  • The above-signed authorizes Vitality Health & Wellness, LLC to keep their signature and credit card information on file in a digitally secure password protected file and to charge their credit card for all charges incurred by them for themselves or the patient that they are authorizing their credit card on behalf of. as per the policy described on this form and the patient registration form.