Resident Salon Service Requests and Payment Set-Up

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For residents that do not have access to their own funds we offer 2 options for paying for services. One option is keeping a credit card on file in our secure system thru the office of Milestone Salon Services. The card on file will be charged bi-monthly with our billing cycle. The other payment option is to be sent a monthly bill. If you prefer this, then you will need to sign a billing agreement and will receive a monthly invoice for the previous month. Please fill this form out to get your payment choice set up.

Name of Resident *

Community Resident Lives In *

Name of Person Responsible for Payments *

Best Contact Phone Number *

Please select Payment Method if you choose to billed please note, the bill is due immediately. If it is not paid with in 15 days there could be a $10 late fee, *

Resident will pay in the salon themselves

Responsible Party Will Set up a Card on File (Call the office at 314-368-8487. Do not email.)

Responsible Party prefers to Billed Each Month (Bills are due immediately) Bills are emailed.

Service(s) Requesting, Please be specific if you have not communicated with the salon provider yet. For example, a shampoo set weekly, haircut every 6 weeks. For appointments please call the stylist at the location. See the last section on this form for phone number. *

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