Payment Form

MEMBERSHIP & ACH AUTHORIZATION CONSENT

WELCOME TO OUR BOTOX CLUB!

As a member, you receive special pricing for Botox all year! Plus, one complimentary facial a year. The following lists the terms of conditions of our Botox Club. Please read carefully, initial at each line, and feel free to ask any questions

I understand that NO REFUNDS or services beyond contract dates are allowed under any circumstance.
I understand that my membership benefits CANNOT be shared, and do not accrue. Discounts and facials are non-transferrable, and facials do not “roll-over” to the following year if unused. I must use the units purchased in a 12 month period. (Requires a minimum of 40 units per tx.)

PATIENT NAME*
First Last
Email*
DATE OF BIRTH*
MM slash DD slash YYYY
NAME WITNESS*
First Last
By signing below, I indicate an understanding of the Botox Club benefits, and the terms and conditions that apply. In addition, I hereby authorize Deborah Longwill DO PA to charge the card listed below for the membership fee.
Signature*