Credit Card Authorization Form

Please 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.

  • If names are listed on this form, you have given Holistic Health Associates approval to take payment on their accounts with the credit card listed on this form.
  • By completing this box, you have digitally signed the Holistic Health Associates Credit Card Authorization form.
  • Date Format: MM slash DD slash YYYY