6928 W. Linebaugh Ave. Suite 102,
Tampa, FL 33625
2445 Country Place Blvd. Suite 103,
New Port Richey (Trinity), FL 34655
© Florida Medspas 2021
THIS AGREEMENT is made on the …………. day of………….20……., (hereinafter, “Effective Date”) entered into by
Florida Medspas (the Company) and _____________(the Client). Company and Client collectively referred to
as the “Parties” or individually as the “Party”) and includes that Party’s successors and assigns.
Payments: The first payment shall be made in advance before commencement of the membership. Thereafter, payments shall
be charged on the client’s file, on the 15 th day of every month in which payments are payable until termination of this
Botox units: Every 3 to 4 months, 44 units of Botox will be made available to you subject to the membership that you have
subscribed to. For additional units, a discounted rate of $9.50 per unit will be made available at your membership appointment.
Juvederm Ultra Syringe: In addition to the Botox Units, one syringe of Juvederm Ultra will be made available to you every
year for the duration of your membership subject to your enrollment in Forever Young or Forever Young every 3 months
membership. Please note that the Saving Face membership DOES NOT include Filler.
Disclaimer: Kindly note that Membership, Botox Units, and Filler are not subject to transfer.
I hereby undertake to have completed my credit application.
I hereby enroll to the following membership (select as appropriate):
☐ Saving Face- $ 99 monthly; this includes 44 units of Botox every 4 months
☐ Saving Face- Every 3 months- $ 134 monthly: this includes 44 units of Botox every 3 months
☐ Forever Young-$ 149 monthly: this includes 44 units of Botox every 4 months and one syringe of Juvederm Ultra yearly
☐ Forever Young Every 3 months-$184 monthly; this includes 44 units of Botox every 3 months and one syringe of Juvederm
*NB. Kindly note to consult the receptionist if you have not completed your credit application.
Dispute and Jurisdiction: This agreement shall be governed by the laws of Florida without regard to its conflict of laws
provision, and any disputes arising herein shall be handled through Arbitration.
Signature: By signing below, you hereby authorize Body Contouring Technologies DBA Florida Medspas to charge the
aforementioned amount on the 15 th day of every month for which payment is due. I also recognize that I can terminate this
agreement at any time subject to serving a 30 days’ notice and settling any balance due and owing for the product or services
Print Name Signature Date
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