Credit Card Authorization Form

Please complete all the fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Credit Card Information
Card Type: ☐ Visa ☐ Discover ☐ Amex ☐ Other
Cardholder Name(as shown on card):
Card Number and Security Code: Code:
Expiration Date(mm/yy):
Cardholder ZIP Code(from credit card billing address):

I, , authorize Healthy Perspectives Inc to charge my credit card above for agreed upon purchases/services. I understand that my information will be saved to a file for future transactions on my account.

Electronic Customer Signature	Date

(We will require your signature at your next visit as well)