Provider Authorization Form

To help us process your order efficiently, please submit your payment details using the secure form below. Your information is protected through our encrypted system.

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Cardholder Authorization

Cardholder Name

(as it appears on card)

Billing Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email Address*

Enter Email Confirm Email

Clinic / Provider Name

(if applicable)

Payment Details

Card Type*

Card Number*

Expiration Date*

Card Type (other)

Note: Emerald does not store CVV/CVC codes. CVV may be used for a onetime transaction only and will not be retained.

Authorization

Cardholder Signature*

Printed Name*

Date Signed*

Terms & Conditions

1. Recurring Billing Consent. Cardholder expressly authorizes Emerald to initiate automatic and recurring charges to the above-referenced credit card without requiring additional signatures or authorizations. This authorization shall remain in full force and effect until terminated in accordance with Section 8.
2. Updated Card Requirements. In the event of any change to Cardholder’s credit card information—including expiration, replacement, new card issuance, or account modification: (a) A new, fully executed authorization form is required prior to Emerald updating or charging the new card; and (b) Emerald shall not accept verbal-only updates for payment method changes. Shipments or services may be suspended until a new written authorization is received.
3. Disputes and Chargebacks. Cardholder agrees to provide written notice to Emerald of any disputed charge and allow ten (10) business days for resolution prior to initiating any chargeback with the card issuer. Cardholder shall not dispute or reverse charges for amounts properly incurred for products or services requested, authorized, delivered, or made available. Emerald reserves the right to re-process improper or reversed chargebacks and recover all associated costs and fees to the fullest extent permitted by law.
4. Revocation and Termination. Cardholder may revoke this authorization only by providing written notice to Emerald at: support@emeraldsrx.com (or such other address designated by Emerald). Revocation: (a) shall not affect charges already incurred, processed, or pending; and (b) may result in suspension of services until an alternative payment method is provided. Emerald may terminate this Agreement at any time upon written notice.
5. Representations and Fraud Prevention. Cardholder represents and warrants that: (a) they are the lawful cardholder or authorized user of the credit card; (b) the information provided is accurate and not fraudulent; and (c) they have full authority to grant the authorization contained herein. Emerald reserves the right to verify identity, decline transactions, or request additional documentation if fraud is suspected.
6. Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Florida, without regard to conflict-of-law principles.

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