Orange Theory Special Rates

1. OTF – MIAMI LAKES FITNESS CHALLENGE
I __________________________________ hereby authorize Healthy Xpress to charge the credit card
(Name of cardholder as it appears on credit card) noted below to satisfy all debts accrued. The authorization and
the information found within are to be used as follows. (Please check box below)
I hereby authorize weekly recurring payments for the value of my order(s).
Customer will select a plan below, and commit to 6 weeks to receive special rate from Healthy
Xpress via the OTF Miami Lakes Fitness Challenge. If customer does not purchase the amount of weeks
below, and cancels he/she will be responsible to pay for the discounts applied. After my commitment is
over, I authorize Healthy Xpress to charge my card on a weekly basis unless I email to cancel the Friday
before the week of service by 6pm.
1. SELECT A PLAN BELOW 2. VIEW OPTIONS 3. TOTAL YOUR AUTHORIZED WEEKLY PAYMENT
(BAG IS ONLY CHARGED DURING THE FIRST WEEK OF YOUR ORDER)
_____ PALEO 3 MEALS + 2 SNACKS x 6 weeks @ $125/wk
_____ PALEO 3 MEALS x 6 weeks @ $105/wk _____ PALEO 2 MEALS x 6 weeks @ $85/wk
_$20_ Cooler Bag & Ice pack (optional) (bag is yours to keep after the service is over.)
* Please leave bags out for driver on delivery days. Each bag not returned w ill incur a $10 charge per bag.
_____ Tip (you will have same driver every day)
Credit Card Information
Credit Card Type: Visa _____ Master Card_____ Discover_____ American Express _____
Card Number: __________________________________________ Expiration Date: __________
CVC/CVV2 (Code in back of card (3-digits o 4 digits for AMEX): __________
Billing Address: ______________________________________________ Zip Code: __________
Shipping Address: ____________________________________________ Zip Code: __________
Email*: _______________________________________ Cell Phone*:______________________
Authorizing Signature: _________________________________________ Date: _____________
I attest to the above information being true to the best of my know ledge. The customer w ill be responsible for any chargeback
charges. Charges w ill show as Geodinamica LLC dba Healthy Xpress.
 I authorize Healthy Xpress to send me promotions via email or Text Message by providing this information.
Delivering A Healthy Lifestyle
_____ TOTAL
www.healthyxpress.com Phone: 1-305-393-8735 Email: info@healthyxpress.com
OFFICE USE ONLY: REP _____ CRM ____ QB _____ RT _____ PD ______ EMAIL______ VOUCHER ___