Total Wellness Solutions

Payment Information
Description	Holiday Gift Card (Buy $200 Get a Free $30 promo credit)
Payment Amount

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

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 affirm that the information entered on this form is true and correct and further declare that I have read, understand and accept Total Wellness Solutions Terms as referenced in the [Terms of Use] link below.

Total Wellness Solutions
5252 Roswell Rd Suite 103 Atlanta, GA 30342
(770) 936-9707

To protect your client's privacy, our secure server uses secure socket layer (SSL). This ensures that the billing information is encrypted and cannot be read as this information is transferred over the internet.