Total Health - Credit Card Authorization Form

Cardholder Information

First Name

Last Name

Company Name (if applicable)

Billing Address

City

State

ZIP Code

Country

Phone Number

Email Address

Credit Card Information

Card Number

Expiration Month

Expiration Year

CVV / Security Code

Payment Authorization

Amount to be Charged ($)

Purpose of Payment

One-time authorization only

Recurring authorization (complete section below)

I authorize Total Health to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only. I certify that I am an authorized user of this 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.

This form is secured with 256-bit SSL encryption. Your information is kept confidential and secure.