Credit Card Authorization Form

Name As it Appears on Card

First Name

Last Name

Card Number

Expiration Date

Card CVV

Billing Address

Suite/Apt

City

State

Zip Code

Email

Phone

(###)

###

####

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Destiny Wellness Center in writing (mail@destinywellnesscenter.net) of any changes in my account information or termination of this authorization at least 7 days prior to the next billing date. I understand that payments may be executed on the next business day from time of service. In the case of a transaction being rejected, I understand that Destiny Wellness Center may charge a $15 NSF fee.