Credit Card Authorization Form (PLEASE COMPLETE, SIGN, PRINT AND FAX TO FILL ORDERS)

SECTION A.

I, , hereby authorize Ojas Med Spa, Inc., to charge my credit card for the amounts I owe. I understand that I waive my right to stop payment or reverse payment on my credit card once processed for product and/or service performed by Ojas Med Spa, Inc. As the credit card holder, I also authorize Ojas Med Spa, Inc. to charge my credit card for future purchases of products and/or services verbally approved by me.

Cardholder Name

Credit Card Number

Expiration Date: / Security Code

Street City State

Zip

If shipping address is different from your billing address, please enter it here:

Shipping Address:

Street City State

Zip

Card Holder Signature Date

Please do not keep my signature on file. I will provide my complete credit card information every time I make a purchase of products and/or services. I understand that I waive my right to stop payment or reverse payment on my credit card once processed for products and/or services performed by Ojas Med Spa, Inc.

Card Holder Signature Date