Deposit/Payment Form
Full Name
*
First Name
Last Name
Phone Number
*
-
Country Code
-
Area Code
Phone Number
E-mail Address
Acknowledgement
By clicking on the circles, you are agreeing to the following:
*
I understand that this deposit is non-refundable, and it is required to secure my appointment date.
*
I understand that if I cancel within 12 hours of my appointment time, there may be a chance that my deposit will be forfeited.
*
I understand that if I show up more than 20 minutes late to my appointment, I may be asked to reschedule.
Signature
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Description
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
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