Common Contracts

Contract

Wellness Program Agreement • February 20th, 2020

• Contract Type
  Wellness Program Agreement
• Filed
  February 20th, 2020

Wellness Program Agreement Your Name: Your Birthday: / / Address: City: ST: Zip: Home Phone: Cell Phone: ( ) - Email: @ . Occupation: Work Phone: ( ) - Card Type:  MasterCard  VISA  Discover  AMEX  Other: Cardholder Name (as it appears on card): Credit/Debit Card #: Exp. Date: / CSC Code: Zip: WELLNESS PLAN CHOSEN: $75.00 PLAN – One 90 Min. Massage/Monthly $50.00 PLAN - One 60 Min. Massage/Monthly To be completed by staff:Initial Payment: Cash  Credit Card Check # Paid in the Amount of $ .00 on the Date of / /20 I, (client), agree to allow Heaven Sent Massage of Ellijay providers to charge my account listed above, in the amount indicated for the Wellness Plan I have chosen, on the 5th Day of each month. This payment is for services provided under the Wellness Program. I agree to allow Heaven Sent Massage of Ellijay to keep my card information on file for the purpose of running monthly payments. This information will be kept secure & confidential. I am aware that my card wil