Aesthetics Credit Card Authorization Form

Client Details

Full Name: *

Email: *

Contact Number: *

Type of charge: *

Recurring Charge
You authorize regularly scheduled charges to your Credit Card or Bank Account. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your Credit Card or Bank Account Statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.

One Time (1) Charge
You authorize the merchant below to make a one-time charge to your Credit Card or Bank Account listed below. By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

I...

Full Name: *

authorize

(Company Name): *

to charge my credit card or bank account below

for: *

$

beginning on: *

on: *

Goods/Services Rendered: *

Billing Details

Billing Address: *

Zip Code: *

Phone: *

Email: *

Credit Card / Bank Account Information

Would you like to use a Credit Card or Bank Account? *

Card Type: *

Visa MasterCard AMEX Discover

Cardholder's Name: *

Credit Card Number: *

Expiration Date: *

(MM/YY)

Security Code (CVV) *

Type of Bank Account: *

Checking Account Savings Account

Name on Account: *

Bank Name: *

Account Number: *

Routing Number: *

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the merchant in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For AHC debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that the merchant may at its discretion attempt to process the charge again within 30 days. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.

Signature: *

Tap or click on the signature above to sign