Clinic Patient Registration Form

New Patient Registration

Please fill in the form below
Name

First NameLast Name
E-mail
example@example.com
Gender
Date of Birth

MonthDayYear
Contact Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Metabolic Weight Management MembershipPeptidesNeurotoxinsLip FillerIV VitaminsVitamin InjectionsLiquid LipoBody ContouringOther
Essential Membership- $449/month (payment plan available)Elevated Membership- $597/month (payment plan available)MARCH MADNESS SALE $249 (1ST MONTH) $399/month LOCK IN RATETEACHER AND STAFF MEMBERSHIP (MUST VERIFY)
Essential Billing Schedule*
If Split Pay is selected, the $249 enrollment fee PLUS the first split installment will be processed at checkout. Remaining installment drafts follow the selected schedule.
Elevated Billing Schedule*
If Split Pay is selected, the $249 enrollment fee PLUS the first split installment will be processed at checkout. Remaining installment drafts follow the selected schedule.
**ENROLLMENT FEE OF $249 IS PROCESSED UPON APPROVAL AND INVOICING. IF SPLIT PAY IS SELECTED, THE FIRST INSTALLMENT IS ALSO PROCESSED AT CHECKOUT. RECURRING BILLING FOLLOWS THE SELECTED SCHEDULE.
I understand that if approved by the physician, I will be enrolled in the selected DynamicDrip Metabolic Weight Management Membership. I authorize DynamicDrip Aesthetics & IV Spa to securely store my payment method and process recurring monthly charges for my selected membership plan. I understand cancellation requires written notice at least 14 days prior to the next billing cycle. I understand that all payments processed are non-refundable.
Signature*

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CONSULTATION FEE-REQUIRED BEFORE SUBMITTING

A $35 consultation fee is required prior to submitting this form. This fee will be applied to approved services.

Click here to pay your $35 consultation fee.
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How did you hear about DynamicDrip Aesthetics & IV Spa?
REFERRAL NAME, IF APPLICABLE
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New Patient Registration