Application. I apply for membership in The Lotus Effect membership program at Bellaire Dermatology. The program set forth requires a 6 or 12 month commitment by the patient whether the membership us utilized or not. I represent and warrant that proper consent for treatment and all facts and information set forth in the Membership Application are true, correct, and complete.
2. Payment. (Select Option)
____ Total Payment: I agree to pay the total commitment amount of $900 for 6 months or $1650 for 12 months (first month free) due today upon signing this Contract.
____ Monthly Payment: I agree to pay monthly committed amount of $150 on the 1st of each month thereafter through automatic withdrawal from an account I maintain in a financial institution pursuant to this signed authorization form. If I change financial institutions, I will provide Bellaire Dermatology in writing all information needed for the replacement automatic withdrawal at least (10) days before the effective date of the change. I agree to the monthly membership fee and acknowledge that the automatic withdrawals (payments) will continue for the _____ 6 or _____ 12 months (select one) period unless I terminate my membership as permitted in this Contract or I convert to another payment option with the consent of Bellaire Dermatology pursuant to a written contract. If I fail to make payment without notification to Bellaire Dermatology, Bellaire Dermatology will have full discretion for unpaid accounts and can take necessary actions to collect any unpaid balances for membership on services provided.
3. Term. All Memberships are either charged on a month-to-month basis from the date of the Start Date unless cancelled in writing or paid at its entirety at the beginning of term. The effective date (i.e. “start date”) of this initial term shall be the date this document is signed.
4. Benefits of Membership.
Access to personal Cosmetic Concierge team for easy scheduling and members needs
Receive a $50.00 gift card to invite a friend to our practice (new patients only).
Receive on complimentary service with our Aestheticians per month
Skin Ceuticals MicroPeel Plus
Focal area of Laser Hair Removal such as the upper lip, chin or under arms
Discount off selected services:
10% off Botox/Dysport
10% off Laser Treatments
15% off Skin Care Products
15% off Cool Treatments
Exclusive Multi Syringe discount, starting at the first syringe:
1st syringe 10% off
2nd syringe 15% off
3rd syringe 20% off
Upgraded Elite Services:
In replacement of complimentary services listed in 4.c.
$175 upgrade fee due at time of treatment: Fotofacial (IPL), Frax 1540 Laser, KTP Laser or Carbon “Hollywood Laser Peel”
Bellaire Dermatology reserves the right to change Benefits of Membership presently in force in the future prescribed by posting notice at least thirty (30) days in advance of change.
Incentive for upfront payment ($1650/12months term only): receive 1st month free.
Cancellation of this membership requires (30) days of advance notice.
All set term payments shall survive the cancellation or termination of this contract.
Bellaire Dermatology reserves the right to revoke or suspend this membership for cause if I fail to keep the rules of this Contract. There are no refunds for membership fees, and Bellaire Dermatology will not prorate a cancelled membership.
6. Non-Refundable/Transferability of Program.
Monthly membership fees, along with complimentary services provided as a benefit of the membership, are non-refundable even if unused. No rollover of missed complimentary services are allowed unless 12 month commitment was paid upfront, only one rollover will be allowed and shall take place at the end of the term commitment.
For further explanation of these program requirements, please discuss with our staff.
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