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Payment Authorization Form

This is a written agreement for your payment terms with My Pure Health Solutions. By signing this agreement, you are confirming and agreeing to the custom payment amount discussed with your MPHS representative.

If paying in FULL: By providing your credit card information below, you agree to make a single payment at a discounted rate.

If opting for a PAYMENT PLAN: your credit card/debit card will be billed monthly for the amount and number of months as indicated in your onboarding email, and each payment will be reflected accordingly on your bank statement.

Customer Information

Please confirm that you have approved the custom payment structure for your weight loss program, shared with you via email.

Please confirm that you have approved the custom payment structure for your weight loss program, shared with you via email.

Credit Card Information

Credit Card Type

Credit Card Type
A
B
C
D

Cardholder Name

Zipcode

Card Number

Expiration Date

CCV

Authorization

I authorize Pure Health Solutions, to automatically bill the card listed below for my Weight Loss Program as follows and will be reflected on my statement as Pure Health Solutions. I also understand and agree by signing this request form, that in the event my credit/debit card is declined, I will be responsible for making the payment within 5 business days of being contacted, and provide a different card for future payments.
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