Total Health - Credit Card Authorization Form (Phone Order)

Customer Information

First Name

Last Name

Company Name (if applicable)

Phone Number

Email Address

Billing Information

Billing Address

City

State

ZIP Code

Country

Is shipping address the same as billing?

Yes

Credit Card Information

Card Type

Cardholder Name (as it appears on card)

Card Number

Expiration Month

Expiration Year

CVV / Security Code

Order & Payment Details

Order Total ($)

Product Category

Order Description / Product Details

Payment Type

One-time payment

Recurring payment

Verification & Authorization

Customer Authorization Confirmation

Customer has verbally authorized Total Health to charge their credit card according to the terms outlined above and has agreed to the Terms and Conditions.

I have verified the customer's billing address and CVV match the information on file with their credit card company.

I have reviewed the Research Use Only terms with the customer and they understand that all products are for research purposes only.

Agent Name

Call Date & Time

Agent Notes

This transaction is processed securely in compliance with PCI-DSS standards. Customer card information must not be stored after transaction processing.