Payment & Financial Policy Agreement

Payment & Financial Policy Agreement
Information About Person Financially Responsible
Your Name*

First NameLast Name
Name of person financially responsible:*
If you are personally financially responsible, enter 'SELF.'
Date of birth:*
Relationship to you:*
If you are personally financially responsible, enter "SELF."
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
NOTICE OF PAYMENT POLICY

Payment is due at the time of service. Accepted methods of payment are cash, PayPal, Cash App, or Venmo. All outstanding balances are payable within 30 days of invoice. If left unpaid after 30 days, a late charge of $10 will be added to the balance. Any balance extended beyond 60 days past due will be sent through collection process. If your balance is sent for collection, you acknowledge that you will be responsible for all collection fees, as well as any legal fees that we incur in order to collect the outstanding deliquent balance.

NOTICE OF CANCELLATION POLICY

Notification via email or phone call is required for cancellations or rescheduling appointments no fewer than 12 hours prior to scheduled appointment time. If you cancel fewer than 12 hours prior to your appointment or do not attend your scheduled appointment, you will be charged the full appointment fee.
I acknowledge the above financial and cancellation policy, and agree to its terms.*

I agree
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Payment & Financial Policy Agreement

Information About Person Financially Responsible