TUMESCENT LIPO SERVICE AGREEMENT Form

TUMESCENT LIPO SERVICE AGREEMENT

Patient agrees to purchase Tumescent Lipo And Downsize agrees to provide such services to the patient according to the following terms and conditions:
Purchase of Services: Name agrees to purchase the following areas area(s) (please initial)
Abs (Upper/Lowers)
Flanks
Hips
Thighs (Inner/Outer)
Axila
Sub Bra Strap
Chin
Arms
Back (Upper/Lower/Mid)
Chest
Knees (Inner/Top)
360 (U/L/F/Sub Bra)
Thighs (Front/Back)
Supra Pubic
Area(s) Quote $
Area(s) Quote $
Area(s) Quote $
Garnment & Binder $
For a Total Fee of $
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Amount Paid:
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Amount Paid:
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Amount Paid:
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Amount Paid:
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Amount Paid:
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Amount Paid:
Downsize has already collected cash or charged my credit card per these terms and will not Recharge me.
Downsize has already charged my LendingUSA/Advantage Care card/Prosper Healthcare per these terms and will not recharge me.
Downsize is authorized to charge my credit card per these terms.
Credit Card:

VISAAMEXMASTERCARDDISCOVER
CC#
CC Expiration Date
Month/Date
Security Code (number on back of Visa or MC or on front of AMEX)
Non-Refundable- Patient understand and agrees this is a binding agreement and that fees paid for all Lipo Procedures are Non-Refundable. I understand that if I decide to have further treatments this consent continues for all subsequent procedures regardless of the time between treatments.

Cancellation Policy- In the event a scheduled procedure must be rescheduled or canceled, 10 business days notice is required. This may be accomplished by calling 832-955-1221. In the event the required notice is not given, you will be assessed $1000 fee. The $1000 deposit is not refundable. If you fail to return your three prescriptions, then you will not receive a refund.

Customer Service- All customer service requests or needs shall be addressed by submitting said request in writing.

- A customer service representative will investigate the request or need and respond.

-Full payment is required 7 days before the procedure.

By placing my signature, I certify that I have read, or have read to me the contents of this form. Further, my signature indicates that I understand the information presented above and have had all of my questions were answered to my complete satisfaction.
Patient Signature

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Print Name
Physician/Staff Signature

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Print Name
Should be Empty: