Name
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First Name
Last Name
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I understand the Elite Skin Membership offers one treatment a month from the following list of procedures: BBL , Chemical Peel, Dermaplane, Microneedling with PRP, Micro-Resurfacing, and Hydrafacial. The treatment plan is specifically customized to my skin care needs and will be performed based on my skin care specialist recommendation.
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Yes I Understand!
I agree to the following membership
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6 Monthly Payments of $150.00
12 Monthly Payments of $125.00
Terms of the membership: The membership is non-transferrable, non-refundable, and may not be used as credit to other procedures. I understand that my credit card will be charged once a month starting the day of agreement and each month thereafter for the length of the contract. If I fail to complete each monthly payment as set forth in the agreement my membership will be cancelled and my credit card will be charged a $250.00 early cancellation fee.
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I agree
In addition to the wonderful monthly procedures, I will receive 25% off all skin products (excluding injectables such as Botox and Fillers). I will also receive a discounted price of $10.00 per unit on Botox.
Yes sign me up!
Last four digits of Credit Card to be used
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Exp Date
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Signature
Submit My Membership
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