Membership Freeze Form

Ascension Healing Studio Wellness Program Membership Freeze Form
Today's Date

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You may freeze your membership up to 6 months for a $10 monthly fee. This fee will be charged to the credit card we have on file for your subscription.

Upon approval of your request for a membership freeze, you will be relieved from making membership dues payments for up to 6-months.
Member No.
If known
Member Name*

First NameLast Name
E-mail*

Confirmation Email
Phone Number*

Area CodePhone Number
Reason for freeze*

Medical ReasonFinancial hardshipOther
How long would you like to freeze your account*

1-month2-months3-months4-months5-months6-months
Freeze Start Date*

MonthDayYear
Freeze End Date

MonthDayYear

Please take a moment to let us know how we've been doing in the following areas:*

	Very Satisfied	Satisfied	Somewhat Satisfied	Not Satisfied
Quality of Healing Services
Availability of convenient appointment times
Cleanliness
Atmosphere of Studio
Kindness and Helpfulness
Overall experience

We are sorry to hear that you are not satisfied with our service. We strive to provide our members with the highest level of service. Your feedback on how we can improve is important to us.
Please tell us how we can improve:
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Ascension Healing Studio Wellness Program Membership Freeze Form