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Membership for Laser Hair Removal - Monthly treatments

.Membership for Laser Hair Removal


I understand that I am signed up for a monthly subscription for laser hair removal treatments. I will receive 1 laser treatment per month on the area size I have selected. 

 I give permission for my credit card on file to be charged every month for the amount of the treatment size I have choose. 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 6th month. If I do not use a treatment one month, it will roll over to the next month, or can be used as credit for other services so the value is never lost. 

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 6 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.

May 9, 2025






































First Members's Name

First Name*

Last Name*

Phone*
First Members's Date of Birth*
First Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
First Members's Signature*
Second Members's Name

First Name*

Last Name*
Second Members's Date of Birth*
Second Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
Third Members's Name

First Name*

Last Name*
Third Members's Date of Birth*
Third Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
Fourth Members's Name

First Name*

Last Name*
Fourth Members's Date of Birth*
Fourth Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
Fifth Members's Name

First Name*

Last Name*
Fifth Members's Date of Birth*
Fifth Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
Sixth Members's Name

First Name*

Last Name*
Sixth Members's Date of Birth*
Sixth Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
Seventh Members's Name

First Name*

Last Name*
Seventh Members's Date of Birth*
Seventh Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
Eighth Members's Name

First Name*

Last Name*
Eighth Members's Date of Birth*
Eighth Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
Ninth Members's Name

First Name*

Last Name*
Ninth Members's Date of Birth*
Ninth Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
Tenth Members's Name

First Name*

Last Name*
Tenth Members's Date of Birth*
Tenth Members's treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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 treatment area selection
Laser Treatment areas, choose as many as you'd like
$49/month - includes 1 of the following areas: lip, chin, neck, cheeks, side burns, jaw line, center eyebrow, ears, center stomach line, areolas, widows peak, knees, feet, hands
$65/month - includes 1 of the following areas: under arms, back of the neck, lower center back
$85/month - includes 1 of the following areas: Bikini, Forearms, inner thighs
$99/month - Includes one of the following areas: full face, Brazilian, full stomach, buttocks
$125/month - includes one of the following areas: lower legs, upper legs, half back, chest, full arms
$250/month - includes 1 of the following areas: Full legs, Full back
$500/month - includes 1 treatment on the full face, underarms, Brazilian, and full legs.

If you would like multiple areas within one section, please specify here which areas. Please note; each area will be charged separately

Credit card number *

expiration date *

cvv code *

billing zip code *

email address *
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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