Credit Card Authorization FormPlease complete all fields. You may cancel this authorization at any time by submitting a signed request to do so. This authorization will remain in effect until cancelled.Cardholder Name (as shown on card)* First Last Name (if different than cardholder name) First Last Card Number* Expiration Date* CVC Code* Card Type* Visa Mastercard American Express Discover Is this an HSA or FSA card?* Yes No Additional Card on FileWhen using an HSA or FSA, Holistic Health Associates requests you keep an additional card on file for herbs and non-service related expenses, as well as in the event your HSA funds run out. Cardholder Name (as shown on card) (Additional Card on File (non-HSA/FSA)) First Last Card Number (Additional Card on File (non-HSA/FSA)) Expiration Date (Additional Card on File (non-HSA/FSA)) CVC Code (Additional Card on File (non-HSA/FSA)) Contact InfoBilling Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone*Card approved for the following additional people. By listing additional names here, you authorize Holistic Health Associates to take payment on these respective accounts for any services rendered, purchases and/or balances with the credit card listed above.Consent* By signing below, I authorize Holistic Health Associates to charge my credit card above for services rendered, purchases and/or balances as outlined in the Financial Policy. I understand that my information will be securely saved on file for future transactions on my account.Signature of Patient, Legal Representative, or Parent/Guardian* Reset signature Signature locked. Reset to sign again By completing this box, you have digitally signed the Holistic Health Associates Credit Card Authorization form. Date* Month Day Year Printed Name of Patient, Legal Representative, or Parent/Guardian* Relationship to Patient PhoneThis field is for validation purposes and should be left unchanged.
