Membership Agreement

Size: px

Start display at page:

Download "Membership Agreement"

Kenneth Osborne
5 years ago
Views:

1 Membership Agreement Name Date Street Address City State Zip Code Home phone Cell Phone Please enroll me in - (Please check the chosen option) [ ] Bronze $79/month (21 to 53% discount) [ ] Silver $99/month (27 to 47% discount) [ ] Gold Yearly: 100 Units of Botox (can divide into up to 4 sessions). $175/month (37 to 47% discount) [ ] Platinum Yearly: 100 Units of Botox (can divide into up to 4 sessions). Yearly: 2 Syringes Juvederm, Belotero or Radiesse (Can divide into 2 sessions). $249/month (35-43% discount)

2 [ ] Club Clear Monthly: Acne facial and acne chemical peel OR Weekly BLU-U Quarterly: Vbeam Laser Full Face Treatment. Yearly: Photodynamic Therapy 1 per year. DEKA Fractional Resurfacing Laser Add On: $400/Treatment $299/month (43-56% discount) Terms and Conditions I understand and agree with the following terms and conditions of this membership: I. Services: Each membership package is described above and offers a set allocation of services to be used during a designated time period. These services cannot be changed or carried forward past the designated time period if unused. Services will be provided at such times as SOMA Skin & Laser is normally open for business. This membership is non-transferable and membership services may not be claimed on your behalf by any other person including family members. II. Dues: Membership dues of $.00 will be due on the first day of each month hereafter until your membership is cancelled or terminated in accordance with this agreement. All balances which are 30 days past due are subject to a $25.00 monthly service fee. In addition, SOMA Skin & Laser reserves the right to: (i) Collect the current and past due balance. (ii) Suspend and/or terminate membership privileges. (iii) Recover from Member any collection fees, court costs, and reasonable attorney s fees. (iv) Collect a service fee of $30.00 for any dishonored check.

3 III. Duration of Membership: Memberships are 12-month term contracts. You may only cancel your membership prior to the expiration of the contract term by performing both of the following: (i) sending SOMA Skin & Laser a written 7-day notice of cancellation prior to the first of the month in which you wish your membership to be cancelled and; (ii) paying to SOMA Skin & Laser the standard non-member price, as of the cancellation date, for any services you actually received during your membership plus a 10% administrative fee. (A 2015 non-member price list is attached to the back of this agreement. All prices are subject to change.) SOMA Skin & Laser reserves the right to cancel your membership by sending you a 7-day notice of cancellation prior to the first of the month in which your membership will be cancelled. In no event, is a refund due to the member. Any notice of cancellation shall be given to SOMA Skin & Laser via fax, , or registered mail return receipt requested, at its fax number, address, or office address, as indicated in the letterhead of this agreement unless SOMA Skin & Laser notifies you of a different number or address. IV. Billing and Credit Card Automatic Payment Authorization: You agree to pay SOMA Skin & Laser all dues, as indicated above, for the duration of your membership and you authorize SOMA Skin & Laser to charge your credit card for your membership dues. You acknowledge that this agreement has a recurring payment feature and you accept responsibility for all recurring charges prior to cancellation of the membership. SOMA SKIN & LASER MAY SUBMIT PERIODIC CHARGES (E.G., MONTHLY) WITHOUT FURTHER AUTHORIZATION FROM YOU, UNTILYOU HAVE CANCELED YOUR MEMBERSHIP IN ACCORDANCE WITH THE TERMS OF THIS AGREEMENT. Current Information Required: YOU MUST PROVIDE CURRENT, COMPLETE AND ACCURATE INFORMATION FOR YOUR BILLING ACCOUNT. YOU MUST PROMPTLY UPDATE ALL INFORMATION TO KEEP YOUR BILLING ACCOUNT CURRENT, COMPLETE AND ACCURATE (SUCH AS A CHANGE IN BILLING ADDRESS, CREDIT CARD NUMBER, OR CREDIT CARD EXPIRATION DATE), AND YOU MUST

4 PROMPTLY NOTIFY SOMA SKIN & LASER IF YOUR PAYMENT METHOD IS CANCELED (E.G., FOR LOSS OR THEFT) AND MAKE OTHER ARRANGEMENTS FOR PAYMENT. Please complete the information below: I authorize SOMA Skin & Laser to charge my credit card indicated below for payment of my SOMA Skin & Laser membership dues each month in the amount specified below in accordance with the terms of my membership agreement. My credit card information is: Billing Address City, State, Zip Phone# Account Type: VISA MasterCard Discover Amex Cardholder Name Payment Amount /Month Credit card number Exp Date CCV(3-4 digit # on front or back of card) Member Signature Date

5 DISCLOSURE: 2016 Non-Member Prices Facials. Facials range from $100 to $125 per treatment. See Microdermabrasion. $125 per treatment. $410 series of 4 Chemical Peels. $150 per treatment, $540 series of 4, $720 series of 6 Vbeam Laser Full Face. $450 per treatment Photodynamic Therapy Full Face. $715 per treatment with Vbeam/ $450 with Blue Light Revlite Laser Full Face. $425 per treatment DEKA Laser for Acne Scarring. $525 per treatment Botox. $17.00/unit Juvederm, Belotero or Radiesse. $640/syringe ***PRICES SUBJECT TO CHANGE***

PATIENT REGISTRATION Date. INSURANCE & BILLING INFORMATION Payment Required At Time of Service Unless Prior Arrangements Have Been Made

PATIENT REGISTRATION Date. INSURANCE & BILLING INFORMATION Payment Required At Time of Service Unless Prior Arrangements Have Been Made PATIENT REGISTRATION Date Name Marital Status Date of Age S/M/W/D/SEP Birth Patient Social Security # Primary Language Race & Ethnicity Street Address City, State, ZIP_ Phone (Home) (Work) Occupation/