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Laser Acne Treatment Membership enrollment

and consent for automatic payment withdrawal

I understand that I am signed up for a monthly subscription for laser acne treatments which include 1 laser acne treatment per week.

 I give permission for my credit card on file to be charged every month for the amount of the option below that I select. I also give permission for my card to be charged a 24 hour $25 cancellation fee if I should miss my appointment or not cancel/reschedule outside of 24 hours before my appointment. I can cancel anytime after the third month. If I do not use a treatment one week, it can be rolled over to the next week.

In the event my card declines for a monthly payment I agree to provide a new form of payment and understand I am responsible for being charged for at least 3 payments. I understand to cancel my membership I must call Laser Luxury at 845-282-3084 or inform one of the staff that I would like to cancel. Canceling can be done any time during the month up to 5 days before the start of the new month.

I Agree

May 5, 2025

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Parent or Guardian's Email Address

Email*
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Membership program
Monthly Membership Program Please Select*
$99 a month for one laser acne treatment per week. Includes $20 off 1 Ance facial
$189/month - includes 1 laser acne treatment a week and 1 Acne Facial a month
$170 /month - 4 laser acne on back every month. Includes 1 free back facial

Credit card number *

Expiration date *

CVV code *

Zip Code *

email *
Authorization to charge card on file *
I authorize
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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