Beauty Membership Sign Up "*" indicates required fields Select Your Membership Level* Diamond Membership $249/month Luxe Membership $189/month Diamond Membership: 100% of your membership payment may be applied toward any services or products 10% discount on all products and services. Botox at $12 per unit. Dysport at $4 per unit Quarterly gifts Birthday gift Free shipping (once per quarter) Exclusive events $250 towards any service on your 1-year membership anniversary Luxe Membership: 100% of your membership payment may be applied toward any services or products 10% discount on all products and services. (Botox and Dysport excluded, offered at the regular tiered pricing) Bi-Annual gifts Exclusive events Free shipping (twice a year) One Time Beauty Membership Enrollment Fee Price: Amount Due Name* First Last Email* Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Beauty Membership Agreement* I have read and agree to the Beauty Membership Agreement below.Monthly membership payments may be rolled over or “banked” on account and must be used within a rolling 12-month period. Membership pricing, promotions and offers are non-transferrable and are for the member’s use only. Promotional vendor programs such as Allé and Aspire Rewards may be used in conjunction with member discounts. For example, if a member purchases Botox, then they get the member rate and they may use their Allé points/coupon. Spa specials and promotions may not be combined with membership discounts. Any membership payment that is declined for insufficient funds, incorrect card information (such as being expired etc) is considered overdue and due to Vibrance Medical Spa. If a membership is considered past due, then membership services and discounts will not be available for use until any past due balance is paid up to and including the current month due. If a membership is past due for more than 10 days, then a $50 re-instatement fee must be paid to Vibrance Medical Spa to re-initiate the membership. Membership payment CANNOT be offset by any in-office credit from patient’s account and must be paid by a Visa, MasterCard, American Express or Discover. Any no-show appointments and cancellations with less than 48 hour notice are subject to a $50 fee and will be deducted from your monthly membership payment. Care Credit CANNOT be used as payment for any service or product purchases in the membership program (as well as monthly membership payment). Members agree to abide by any and all Vibrance Medical Spa policies. Any and all membership fees are not refundable. Membership funds on account must be used within one year of initial enrollment date. All membership terms are on a month-to-month basis and member’s credit card will automatically be charged on the 5th of every month. To cancel a membership, we require a written 30 day notice prior to your next monthly membership charge. Please email our Membership Coordinator, Nichole at nichole@vibrancemedispa.com with your written cancellation notice. She will then a brief appointment to review any remaining credits or gifts on your account. NOTICE TO MEMBER: DO NOT CONSENT TO THIS AGREEMENT UNLESS YOU HAVE READ IT IN ITS ENTIRETY. PLEASE READ AND UNDERSTAND THIS AGREEMENT BEFORE CHECKING THE CONSENT CHECKBOX. After your information has been submitted one of our staff will contact you to complete your enrollment. 66473