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Recurring Credit Card Authorization Form

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Weight Management Program

I authorize Verve Health LLC to charge my card on the amount indicated in this form on a monthly basis, and shall remain in effect until I request for the cancellation or termination.

I likewise certify that I am the authorized user of the Credit Card that shall be submitted through this form. As long as the transactions correspond to the terms and conditions indicated in this authorization, I shall not raise disputes against Verve Health LLC.

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Semaglutide Monthly Membership $329.00

Your Semaglutide monthly membership includes your Semaglutide shipped to your home every 5-6 weeks, along with on-going support, appointments, and medication management. This membership accommodates doses up to 1mg (40 units) weekly. Your card will be charged monthly to make the monthly billing process more seamless. If you would like to cancel your Semaglutide monthly membership, please email Verve Health at info@vervehc.com at least 24 hours prior to your monthly charge date.

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Recurring Credit Card Authorization Form

Weight Management Program

Patient Info:

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