Credit Card Payment Authorization Form

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Credit Card Payment Authorization Form
Sign and complete this form to authorize Dr. Kieran Kuykendall to bill my credit, debit, flex or HSA card listed below.

Please complete the information below:
I, (Full name)*
I authorize Dr. Kieran Kuykendall to charge my credit card as listed below.
Email*
Phone*
Date of Birth*
MM slash DD slash YYYY
Billing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Shipping Address (If different than billing address):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The entire contents of this website are based upon the opinions of Dr. Kieran unless otherwise noted. Individual articles are based upon the opinions of the respective author, who retains copyright as marked. The information on this website is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Dr. Kieran and his community. Dr. Kieran encourages you to make your own health care decisions based upon your research and in partnership with a qualified healthcare professional. These statements have not been evaluated by the Food and Drug Administration. Dr. Marchegiani’s products are not intended to diagnose, treat, cure or prevent any disease. If you are pregnant, nursing, taking medication, or have a medical condition, consult your physician before using any products.