ProActive Health and Wellness

Order Details
Description	Massage Membership Registration Form
Payment Made Now
Recurring Payment	$55.00 Monthly auto-debits starting 06/08/2024

Contact / Shipping
First Name*
Last Name*
Email*
Verify Email*
Address
City
State
Zip
Country
Phone
Birthday

Billing Address
Copy Contact
Billing Address*
Billing City*
Billing State*
Billing Zip*
Billing Country*

Billing
Name On Card*
Credit Card Number*
Card Expiration Date*	/
Card Verification Code*	what's this?

First Name on Account*
Last Name on Account*
Bank Name*
Routing Number*	what's this?
Verify Routing Number*
Account Number*
Verify Account Number*

*Required

I authorize ProActive Health and Wellness to debit the account listed hereon $55.00, & agree to perform the issuer obligations. I authorize ProActive Health and Wellness to auto-debit the account listed hereon $55.00 Monthly starting 06/08/2024 & agree to perform the issuer obligations. I affirm that the information entered on this form is true and correct and further declare that I have read, understand and accept ProActive Health and Wellness Terms as referenced in the [Terms of Use] link below.

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ProActive Health and Wellness
440 Beecher Road Gahanna, OH 43230
(614) 337-8111

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