HALO Membership Auto Draft Consent
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Email
*
example@example.com
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Monthly Membership Types (1 time $49 Setup fee)
*
VIP Membership platinum, gold, silver
Laser Hair Removal Membership
Iv Therapy Membership
Brazilian Wax Membership
Spray Tan Membership
Desired Payment Option
*
Annually (Pay All At Once Now)
Bill My Card on File
Banking Institution
BOA, Sandia CU, ect.
Bank Account Name
*
Savings or Checking
Bank Account Number
*
Routing Number
*
Banking Institution Phone Number
-
Area Code
Phone Number
I agree to allow Halo Med Spa to auto-draft the specified membership amount on the 1st of each month for a period of one year unless I have chosen to pay annually. Auto-renewal will be in effect unless I make arrangements with Halo Med Spa management before the 12th billing cycle. I understand that insufficient funds may result in immediate cancellation of my membership, and no refund will be issued. If my account is more than 30 days past due, my membership will be canceled. An early termination fee of $199 will be charged if I have not fulfilled the required six month or one year commitment at the time of cancellation, and this fee will be automatically billed to my card on file. I acknowledge that unused membership benefits will not roll over to the following month. A one-time account pause is allowed for up to three months without penalty. All changes must be submitted in writing and approved before taking effect on my membership.
*
I agree to the above.
Patient Signature
*
Submit
Should be Empty: