Cancellation Fee Agreement

Cancellation Fee Agreement

Please complete this form with the understanding that we have implemented a strict cancellation policy. You will not be charged unless you cancel within 24 hours.

Cancellation Fee

This fee will be charged if the appointment is cancelled within 24 hours.

$75.00 Quantity

Total

Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
By signing below I hereby authorize the company to charge my credit card for the amount shown above as a cancellation fee if I cancel my appointment within 24 hours.
Authorization Signature
Should be Empty: