VIP Membership Authorization Form

VIP Membership Authorization Form
Name*

First NameLast Name
Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Tier Status

Please select which tier option you think will suit you best. If you are unsure and need help deciding, please contact us!
I would like to enroll in the _______________________.*
"Card on File"

Please provide the card you would like to be billed monthly. This will be submitted on a secure, password protected form, that merges directly to our patient processing system. If you prefer to sign up and provide payment information over the phone, please skip this portion and call us at 802-528-2738 or signup right in-office!
Name on Card - please contact us if this does not match your name

First NameLast Name
Payment Processing Network
Ie. Visa, Mastercard, AMEX, Discover
Card Number
CVV Code
Security Code
Expiration Date
Billing Zip Code
If we are unable to get the provided information to process, we will contact you. You will not be enrolled into the program until your first deposit has been made.
Terms & Conditions:

Refunds:

Any funds deposited into Empower MedSpa's VIP Membership Program are non-refundable.

There are no exceptions to this policy, whatsoever.

Exiting the program:

If you choose to forfeit your membership, which you may do so at any time, you will be encouraged to spend the remaining balance in your Beauty Bank. If, for some reason you are unable to spend the remaining funds, the money may be transferred to a gift card and re-gifted to another individual, although the membership status discount will no longer be honored. Discounts and member perks will only be honored for the original membership holder. If you choose to exit the program, you will be required to provide Empower MedSpa with at least a 14-day notice. This is to ensure the automatic charge is cancelled in an appropriate timeframe. If you fail to give a 14-day notice, please know that your card may automatically be billed for the following month and that transaction will not be refunded.

Payment:

To maintain active status in our VIP membership program, you will be required to deposit a specific amount of funds in your Beauty Bank every month. Once you choose which membership option will suit you best, you will authorize Empower MedSpa to withdraw the appropriate funds from your "card on file" in the third week of every month. If you need to change or update your "card on file", which you may do at any time, you will be expected to call Empower MedSpa in the first week of the month to do so. If your "card on file" gets declined or is unable to be processed, we will contact you. If we don't hear back within 24 hours, you will have 5 business days to contact Empower MedSpa to update your card information. If you fail to do so, Empower MedSpa reserves the right to withdraw you from the program and your exclusive spot may be offered to the next individual on our waitlist. Financing programs such as CareCredit or Cherry for Alle, may not be used to pay your monthly membership dues.

Beauty Bank Funds:

The funds that are deposited into your Beauty Bank, are yours to use how you please. This program is intended to take away the hit of large transactions by allowing you to merge your esthetic priorities into your monthly budget. Beauty bank funds do not expire and may be rolled over to the following year. No more than $1,500 may be rolled over. If you have more than $1,500 in your Beauty Bank by year end, you will be required to spend it - even if it's spent by placing a deposit towards a future treatment on your wish list.

No shows/Late Cancellations

If you no show or late cancel an appointment while you are enrolled in the VIP membership program, Empower MedSpa reserves the right to deduct necessary funds from your Beauty Bank, to the cover the cost of your fee, per our cancellation policy.

Adjusting your membership status:

You may upgrade or downgrade your membership at any time. Your new benefits will take place on the day of your first status change transaction.

Promotions:

Funds in your Beauty Bank and your VIP discount, may not be used or combined with any other promotion at any time. There are no exceptions to this. This includes sales packages such as Emsculpt, Laser Hair Reduction, BBL, etc., monthly specials, flash promotions, product discounts, training or model discounts or any other discounts offered at Empower MedSpa. You will be offered whichever discount is larger whether it be the promotional discount or your membership discount. If the promotional discount is larger and you choose to accept it, you will not be able to use your Beauty Bank funds for that purchase - you will be required to pay separately with cash, credit, or debit. Membership holders may not use their discount to purchase Gift Cards.

You MAY use your Beauty Bank funds in conjunction with Alle or Aspire points.
Signature*

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By signing above, I agree that I have read the terms and conditions in full and agree to be compliant with them. I understand that Empower MedSpa has the right to withdraw me from the program at any time, for any reason. By signing this form, I authorize Empower MedSpa to charge my "Card on File" the appropriate amount, selected by me, one time monthly. I am aware that I will have full access to these funds unless no show/late cancellation fees are deducted. Should I choose to exit the program, I agree to give Empower MedSpa no less than a 14-day notice.
Should be Empty:

VIP Membership Authorization Form

Tier Status

"Card on File"