To provide an additional layer of protection, we request that you contact Wellness Grove in order to communicate your card number, expiration, and security code at (330) 915-2907. If we do not hear from you prior to your appointment, we will reach out to obtain this information.
Please note that this authorization form is only valid for the card number, expiration, and security code that matches the card type and name as it appears on the card which has been provided on this form.