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Credit Agreement


I, [Patient/Authorized Person Name], hereby acknowledge and agree to the

following terms and conditions for the use of the provided credit card for

payment purposes at [Clinic/Organization Name]:

1. I authorize the use of the provided credit card for payments related to

services received at the clinic.

2. I understand and agree that I am responsible for any charges incurred

using this credit card.

3. I agree to comply with the clinic's payment policies and will resolve

any disputed charges directly with the clinic.

4. I authorize the clinic to charge the provided credit card for the

outstanding balance of services rendered.

5. I understand that this authorization will remain in effect until I provide

written notification of its termination.

I acknowledge that I have read and understood the terms of this credit

agreement and agree to be bound by them.

Authorized Person's Name: __________

______________

Date: ______ December 22, 2024________



Clinic/Billing Information

Physician or Advanced Practitioner Name AND NPI Number *

Clinic Name *

Clinic Address *

Name on Card *

Credit Card Number *

Expiration Date *

CVV *

Billing Address *

Practice Type: In office, ship to patient, or both? *

Sales Rep Name:

Preferred Method of Sending Prescriptions LifeFile or ePrescription or Fax?
First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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