Referral Submission Form – Optimize by JaeNix
Submit your referral to Optimize by JaeNix and help your friends access our services. Referrers and referred clients can both receive incentives when eligibility criteria are met.
SECTION 1 — REFERRER INFORMATION (Person submitting the referral – YOU)
Your Full Name
*
First Name
Last Name
Phone Number (This number will be used to send your $25 referral payout via Zelle or Apple Pay.)
*
Please enter a valid phone number.
Preferred Payment Method
*
Zelle
Apple Pay
Email Address
example@example.com
Are you:
*
A current patient
A former patient
A friend/family member
Other
SECTION 2 — REFERRED CLIENT INFORMATION (The person you are referring to Optimize by JaeNix)
Client Full Name
*
First Name
Last Name
Client Phone Number
*
Please enter a valid phone number.
Client Email Address
example@example.com
Has the client agreed to be contacted by Optimize by JaeNix?
*
Yes
No
SECTION 3 — SERVICE OF INTEREST (Select all that apply)
Which service(s) is the client interested in?
*
Aesthetic Injectables (Botox, fillers)
Medical Weight Loss (Semaglutide / Tirzepatide)
Hormone Therapy (BHRT / TRT / Perimenopause care)
Peptide Therapy
IV Therapy / Injection Bar
Wellness or metabolic consultation
Not sure / needs consultation
Additional notes about the client or referral
SECTION 4 — REFERRAL INCENTIVE TERMS (REQUIRED ACKNOWLEDGMENT)
Please review and acknowledge the following:
*
I understand I will receive $25 via Zelle or Apple Pay only if the referred client books an appointment with Optimize by JaeNix, completes the service, and pays for the service in full.
I understand referrals are unlimited.
I understand the referred client will receive a $25 credit toward their next appointment after completing their initial paid service.
I understand referral payouts are typically processed within 5–7 business days after the client completes and pays for their service.
I confirm the phone number I provided is correct for payment delivery.
SECTION 5 — ATTESTATION
I attest that the information submitted is accurate to the best of my knowledge and that the client has consented to being contacted.
Referrer Name (Type your full name)
*
Signature
Date
*
-
Month
-
Day
Year
Date
Submit Referral
Submit Referral
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