Fill in this agreement, download your copy, and send a copy to AZSkinLab. It covers a down payment plus installments for your treatment.
Takes about 3 minutes. When you submit, your completed agreement is emailed to AZSkinLab.
AZSkinLab • 3131 E Thunderbird Rd, Phoenix, AZ 85032 • (415) 718-3998
AZSkinLab • 3131 E Thunderbird Rd, Phoenix, AZ 85032 • (415) 718-3998 • [email protected]
Date of agreement:
Full name:
Phone:
Email:
Address:
Treatment or service:
Total cost ($):
Down payment ($): — Down payment due date:
Remaining balance ($):
Choose one: — Amount of each installment ($):
How often:
First installment due date:
| Payment | Due date | Amount ($) |
|---|
Late fee amount ($):
I agree to pay the total cost above under the plan selected, including any late fees that apply. If I choose to stop treatment, any remaining balance for services already received is still due. Both parties keep a signed copy.
Type your full name as your signature: — Date:
Client signature: ______________________________ Date: ______________
AZSkinLab representative signature: ______________________________ Date: ______________