Alessifxhealth.com
Ascend Functional Health
3916 N Dartmouth Ave
Tampa, FL 33603
(813) 284-7222

6-Week Challenge - 3 Payments (3x299)

Order Details
Description	5% discount for each added challenger
Number of Challengers*
Payment Made Now
Recurring Payment

Contact
First Name*
Last Name*
Email*
Verify Email*
Phone*

Billing Address
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 Ascend Functional Health to debit the account listed hereon $299.00, & agree to perform the issuer obligations. I authorize Ascend Functional Health to auto-debit the account listed hereon 2 auto-debits of $299.00 starting & 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 Ascend Functional Health Terms as referenced in the [Terms of Use] link below.

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Ascend Functional Health
3916 N Dartmouth Ave Tampa, FL 33603
(813) 284-7222

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