Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will
remain in effect until cancelled. Cancellation of any unlimited membership plan must be requested no sooner than 30 days prior to cancellation date. Please note: unlimited memberships require a minimum of a two (2) month commitment to payment.

Cardholder Name (as shown on card) *
Cardholder Name (as shown on card)
3-digit number on the back of your card
Authorization *
I authorize Hands of Hope Chiropractic & Wellness Center to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future  transactions on my account.
Acknowledgement *
Completing this form verifies that you agree to authorize Hands of Hope Chiropractic & Wellness Center to charge your card for a minimum of three (3) months and agree that in the case you decide to cancel your membership, you will provide notice no less than thirty (30) days prior to cancellation date.