Patient Name
Date of Birth
Address
Phone Number
Email
Cardholder Name
Card Type (Visa/MC/AmEx/Discover)
Card Number
Expiration Date
Billing Address (if different)
CVV
By signing this agreement, I authorize Lakeland Cryo & Reshaping to charge my credit card for services and fees in accordance with the terms below:
Monthly Fee: $299 to $600 per month, depending on program, peptide, and dosage. Fees may be higher if additional medication or higher doses are required.
Pre-Purchase of Medication: Medications are purchased in advance on the patient’s behalf. All medication purchases are non-refundable once ordered.
Minimum Commitment: Three (3) month minimum program commitment. If discontinued before the 3-month period ends, the patient remains responsible for all monthly fees through the end of that term.
Cancellation Policy: Written notice of cancellation must be provided at least three (3) weeks prior to the next scheduled billing date.
Appointment Policy: If the patient fails to attend a scheduled pickup or treatment appointment without timely cancellation (24 hours’ notice), the full appointment fee will be charged (e.g., $600 if scheduled for a $600 appointment).
Maintenance Program: After completion of the initial program, patients may enroll in a maintenance program at ½ of the monthly amount + $75/month for medical oversight.
Medical Oversight: This is a licensed medical practice. All medications are prescribed and supervised by a medical provider. Medications/vials are dispensed only pursuant to a prescription and are not sold directly.
Treatment Plan Activation: No monthly charges will occur until a licensed provider prescribes and initiates a medical treatment plan.
First Appointment No-Show: If the patient fails to attend their first appointment without at least 24 hours’ notice, a $100 no-show fee will be charged to the card on file.
Refund Policy: Due to the medical nature of services, all fees and pre-purchased medications are non-refundable once services or prescriptions have been initiated.
Patient Responsibility: The patient is responsible for providing accurate medical history and promptly reporting any side effects or concerns. Failure to follow prescribed protocols may impact treatment outcomes.
Cardholder Agreement: I certify that I am an authorized user of the credit card listed above and agree not to dispute scheduled payments with my credit card company, provided that such charges correspond to the terms outlined in this agreement.
I understand and agree that:
I am financially responsible for the costs associated with my treatment program.
I have had the opportunity to ask questions about my treatment plan and associated fees.
I consent to treatment and acknowledge that results may vary and are not guaranteed.
I release Lakeland Cryo & Reshaping and its providers from liability for non-medical outcomes (e.g., aesthetic dissatisfaction) so long as the treatment is rendered according to standard medical practice.
I have read and agree to all the terms and policies above
Patient Name (Print)
Patient Signature:
Date
Cardholder Name (Print)
Cardholder Signature (if different from patient)
