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DAILY NUTRITION VITAMIN PILL PACK PAYMENT FORM

Name

First NameLast Name

SELECT A Health MD Vitamin Pack Subscription

Address

Street Address

Street Address Line 2

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Postal / Zip Code

Email

example@example.com

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Please enter a valid phone number.Format: (000) 000-0000.

My Subscriptions

Monthly Vitamin Pill Pack Subscription

Health MD subscription for monthly vitamin pill pack.

$95.00 for each month

Credit Card

Signature

Credit Card Authorization & Subscription Consent

I hereby authorize Health MD to charge my credit card on file for the monthly vitamin pill pack subscription fee in the amount agreed upon at the time of enrollment. I understand that this is a recurring monthly charge, and I authorize Health MD to process this payment automatically each month until I cancel my subscription in accordance with the company’s cancellation policy.

I acknowledge that it is my responsibility to ensure that my payment information remains current and valid. If my payment method is declined, I understand that Health MD may attempt to reprocess the payment and/or suspend my subscription services until payment is successfully completed.

I understand that I may cancel my subscription by providing notice as outlined in the program terms and conditions. I further acknowledge that any charges processed prior to cancellation, including those already in billing cycles, may be non-refundable unless otherwise stated.

By signing below, I confirm that I am the authorized cardholder and that I have read, understand, and agree to the terms of this authorization.

The Enterprise Business Center of Louisiana provides accounting and billing services. Look for the name on your credit or debit card Enterprise Business Center each month on your credit or debit card statement.