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AcuBay Membership
Welcome to AcuBay Clinic's own Membership Deal!
This form will only available in the month of July 2021 as it is an early bird special.
Memberships last from August 2021 to July 2022.
Please fill out your information and we will be in contact with you shortly for confirmation.
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Name (First and Last)
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Your answer
Email
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Your answer
Phone
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Your answer
If you are visiting our clinic for the first time, first consultations are $250. After the first consultation, the AcuBay Membership will go into effect. Are you okay with that?
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Yes
No
Do you agree to a one-year commitment with us?
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Yes
No
Do you agree to a monthly automated charge of $90 for 12 months?
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Yes
No
Do you agree to input your card details once we send an invoice for the monthly automated charges? (Saving card on file)
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Yes
No
Please be advised that unused sessions in that month cannot be rolled over the the next month.
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Yes
No
You can cancel anytime and use any remaining sessions within 90 days of cancellation date.
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Yes
No
If you wish to come for another appointment, the second session will be $90 but all other sessions (3rd, 4th, etc) will be $100.
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Yes
No
You can transfer your unused sessions to a family member older than 13 years old.
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Yes
No
Do you agree to officially sign an agreement in person? (Signature)
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Yes
No
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