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 - Monthly Price $199
Laser Hair Removal Membership Extra Large - $260
Laser Hair Removal Membership Large - $169
Laser Hair Removal Membership Medium - $109
Laser Hair Removal Membership Small - $99
Laser Hair Removal Membership Extra Small - $89
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 listed membership amount on the 1st of each month for (1) year unless I have selected to pay annually. Auto renewal will be active unless the client makes arrangements with Halo Med Spa management before the 12th billing cycle. I understand that failure to have sufficient funds may result in immediate cancelation of my membership and a refund will not be issued. After 30 days past due cancelation of the membership will be processed. An early termination fee of $199 will be assessed if you have not met the required 1 year commitment at the time of cancelation and automatically billed to your card on file.
*
I agree to the above.
Patient Signature
*
Clear
Submit
Should be Empty: