CANCELLLATION and NO SHOW POLICY/FEE AGREEMENT
Your scheduled appointment is reserved exclusively for you. We understand that certain events or situations come up and prevent you from being able to make your scheduled appointment or cancel within 48 hours. Please communicate to management if this occurs and management will evaluate your individual situation. If you need to cancel or reschedule your appointment, please notify us at least 48 hours in advance to avoid a charge. There will be a fee of $50 per hour of service scheduled for Coolsculpting Treatments and a fee of 20% of your service for all other procedures (i.e. lasers, peels, facials) that are not cancelled with proper notice. Please sign & date below to acknowledge this cancellation policy and agree to being responsible for this payment if your appointment is missed without the 48-hour notice.
PRINT NAME:________________________________ SIGN NAME:________________________ DATE:______________________
CREDIT CARD ON FILE AUTHORIZATION
I understand that I am financially responsible for the purpose(s) stated on this policy and authorize Head to Toe Med Spa to run my credit card for all purpose(s) stated on this policy.
Card#:__________________________________________ Type: Visa Mastercard Amex Discover Other:________ Exp:___________
Name on Card:___________________________________ Sign Name:__________________________________ Date:__________
PATIENT FINANCIAL RESPONSIBILITY ACKNOWLEDGEMENT
At this time, Head to Toe Med Spa does not accept insurance for services. This means all cosmetic and medical visits are cash pay and 100% responsibility of the patient. Please sign & date below to acknowledge this statement. If you have any questions about the pricing of your services today, please feel free to inquire before your appointment begins.
PRINT NAME:_____________________________ SIGN NAME:______________________________ DATE:_________________