Mister Meds Method of Payment Form

AUTHORIZATION FOR CREDIT CARD ON FILE

to revoke request

Credit Card Type

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Please list anyone other than the cardholder that is authorized to use this credit card.

I hereby authorize Mister Meds, LLC to charge the credit card listed above for the payment of all prescription orders. This credit card will be kept on file and will remain in effect until the expiration of the credit card account. Applicants may revoke this credit card on file by submitting a written request to the address at the top of this form. A new form must be submitted if any information such as credit card expirations or authorized users is changed. Applicants agree to pay the cost for any returned or challenged payments.

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Middle

Last

Date of Signing

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Card Number:

Expiration Date:

CVV Code (Security Code):

Billing Address:

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Mister Meds Method of Payment Form

AUTHORIZATION FOR CREDIT CARD ON FILE

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