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Facial Membership enrollment

and consent for automatic payment withdrawal

Laser Luxury Membership Consent Agreement

I acknowledge and agree to enroll in a monthly subscription for facial treatments at Laser Luxury. As part of this membership, I will receive one treatment per month based on the service option I have selected.

I authorize Laser Luxury to charge my credit card on file each month for the agreed-upon amount corresponding to my selected treatment. I also authorize a $25 fee to be charged to my card in the event that I miss an appointment or fail to cancel or reschedule with at least 24 hours' notice.

This membership requires a minimum commitment of four (4) monthly payments. After the fourth month, I may cancel at any time by notifying Laser Luxury either by phone at (845) 282-3084 or in person by informing a staff member. Cancellations must be made at least five (5) days prior to the start of the next billing cycle in order to avoid being charged for the upcoming month.

If I do not use my monthly treatment, the service will roll over to the following month or may be applied as a credit toward other services of equal or lesser value. Credits do not expire as long as the membership remains active.

In the event my payment method is declined, I agree to provide an updated form of payment. I understand that I remain financially responsible for a minimum of four (4) monthly payments regardless of payment processing issues.

By signing below, I confirm that I have read, understood, and agree to the terms and conditions of this membership.

I Agree

September 16, 2025

First Client's Name
First Name*
Last Name*
Phone*
First Client's Date of Birth*
Date of Birth
First Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Client's Date of Birth*
Date of Birth
Second Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Client's Date of Birth*
Date of Birth
Third Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Client's Date of Birth*
Date of Birth
Fourth Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Client's Date of Birth*
Date of Birth
Fifth Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Client's Date of Birth*
Date of Birth
Sixth Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Client's Date of Birth*
Date of Birth
Seventh Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Client's Date of Birth*
Date of Birth
Eighth Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Client's Date of Birth*
Date of Birth
Ninth Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Client's Date of Birth*
Date of Birth
Tenth Client's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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*
Date of Birth
Parent or Guardian's Membership program
Monthly Membership Program Please Select*
$69 a month for one 50-minute facial • Includes 1 free add on service for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one Hydro facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
$99 a month for one IPL Photo facial a month • Includes 1 free collagen mask for the first month • Includes 10% off all other add on services • Includes 10% off all facial products
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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