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Credit Card Authorization Form

Contact Information (Credit Card Owner)

Your Name (Credit Card Owner)(Required)

First Last

Your Email (Credit Card Owner)(Required)

Your Phone Number (Credit Card Owner)(Required)

Your Current Address (Credit Card Owner)(Required)

Street Address Address Line 2 City State ZIP Code

Photo Of Your Government Issued ID (Must Match Credit Card Name)(Required)

Accepted file types: jpg, png, pdf, heic, jpeg, Max. file size: 5 MB.

Credit Card Number(Required)

Credit Card Expiration Date(Required)

Credit Card CVV(Required)

Credit Card Billing Zip Code(Required)

Contact Information (Authorized User)

Name Of Authorized User(Required)

First Last

Email Of Authorized User(Required)

Phone Number Of Authorized User(Required)

Specific Authorization Amount Or Limit(Required)

If you only want to specify a specific amount or final limit on how much this credit card can be charged, please specify it here. If their is no limit, please mention it.

Is this a one time approval, or do you accept all future authorizations?(Required)

One Time Approval

All Future Authorizations Are Approved

Today's Date(Required)

By signing here, you agree and authorize your credit card to be charged by Beauty Vault Med Spa staff towards any services or products for the authorized user indicated in this authorization form. You agree that there is absolutely no refunds on any products and services purchased by the authorized user. You agree that Beauty Vault Med Spa has the ultimate right of refusal to complete any treatments that Beauty Vault Med Spa staff may deem unfit for the patient, and that Beauty Vault Med Spa has the ultimate right of refusal in honoring this authorization form, if there is any indication that this form was submitted under fraudulent pre-tenses. You agree that in order for Beauty Vault Med Spa staff to complete any services or treatments for a patient that visits our clinic, that the patient must at minimum sign consent forms allowing the treatment to be completed by Beauty Vault Med Spa staff. You understand and agree that Beauty Vault Med Spa staff may require the patient/authorized user to also submit a photo ID and valid credit card to be held on file in order to receive any treatments at our clinic. Due to privacy compliance, Beauty Vault Med Spa may not be able to provide you specific details on what services or treatments was purchased and completed without prior approval by the patient (authorized user) themselves, we can however provide you a copy of the receipt (without any specific treatment details) if directly requested.(Required)

Treatments

Neurotoxins

Fillers

Skin Discoloration

Credit Card Authorization Form

Contact Information (Credit Card Owner)

Contact Information (Authorized User)

Treatments

Neurotoxins

Fillers

Skin Discoloration

Credit Card Authorization Form

Contact Information (Credit Card Owner)

Contact Information (Authorized User)

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