WP E-Signature by Approve Me - Sign Documents Using WordPress -

Credit Card Authorization and Cancellation Policy

At Dermatology Partners we are dedicated to treating our patients with the utmost respect for their time. The time we set aside for your appointment is time dedicated in whole to your treatment, your concerns, your questions and your feedback. We view your time as valuable, and ask you reciprocate that sentiment.

A credit card is required to book any aesthetics service at Dermatology Partners. There are no exceptions to this policy.

Cancellation Policy: Should the client choose to cancel the appointment, they may do so 24 hours prior to the scheduled service. Not providing the full 24 hours for cancellation will result in a cancellation fee equal to the charge of the service scheduled. This notice must be given by calling Dermatology Partners directly and notifying the staff of the cancellation.

No Show Policy: lf a client gives no notice and does not arrive to an appointment, they will be charged a no show fee equal to the charge of the service scheduled. A no show will also refer to a client who arrives more than 20 minutes past the scheduled appointment time.

We do our best to confirm all appointments at least 2 days in advance, but this is a courtesy call only. Ultimately it is your responsibility to maintain records of all your upcoming appointments.

This form is to affirm that I understand the terms of the cancellation policy set forth by Dermatology Partners and that I authorize the use of my credit card should I cancel or no show for an appointment. I understand this card will be kept on file, using a secure website. I also understand it is solely my responsibility to keep track of my upcoming appointments.

Date:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

May 6, 2020 3:51 pm MDT

Credit Card Authorization and Cancellation Policy Uploaded by Dermatology Partners Inc - ilan@ntmatter.com IP 181.166.195.138