ONLINE Beauty Bank Agreement

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Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

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Email* This field is required.

example@example.com

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Are you a new patient?If you have NOT been into the office before, you are considered a new patient. If you are here in the office, you are not considered a new patient.

I have never been seen at the office before

I have been seen at the office before

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BEAUTY BANK AGREEMENT - READ IN FULL- PLEASE DOWNLOAD & KEEP FOR YOUR RECORDS. By Signing Below, you acknowledge that you have read this agreement in full and completely understand the terms.

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New Patient Deposit* This field is required.

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Full Agreement Read & Saved* This field is required.

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Recurring Monthly Payment & Billing Date* This field is required.

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Cancelation and No-Shows* This field is required.

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3 Month Recurring Billing Requirement* This field is required.

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Card Declines, Deadlines, and Late Fees* This field is required.

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Today's Payment & Recurring Monthly Payment Start* This field is required.

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Auto-Cancel & Membership Forfeit* This field is required.

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Declined Payment Penalties* This field is required.

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2nd Card on File* This field is required.

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Cancelation Terms* This field is required.

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Reinstatement* This field is required.

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No Refunds* This field is required.

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CARD ON FILE* This field is required.Please provide a card for your file, which will be charged $149.00 to initiate your membership. For membership reinstatements, we'll contact you before processing. The card must be in your name; if not, email SUPPORT@WINDERMEREMEDICALSPA.COM for a credit card authorization form.

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By signing below, I agree to the full terms and conditions in the Beauty Bank Agreement. I have read the agreement in full and saved it. I understand every policy. I agree to the monthly payment structure, and that my first recurring monthly membership payment date is not today. I am ready to begin my membership today.* This field is required.

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