Perfect Teeth Membership Form
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I understand that I am fully responsible for setting and keeping my membership appointment(s), if I am a no show or don't set an appointment within 6 months of my contract end date Picture Perfect has the right to forfeit the contract.
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I understand that payments of $13.00 will be rendered monthly on the 15th of each month I understand that there are no refunds I will receive 1 complete led whitening every 6 months. Today’s $5.00 activation fee will be applied to the first month draft.
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I understand that if I cancel my contract any time before my anniversary date that there is a $25.00 early cancelation fee. I understand to avoid a cancelation fee I will need to submit a letter in writing, and services will be canceled on my anniversary date. I understand that this fee may be waived if I have been a member longer than 18 months.
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I understand any changes to my account information must be sent to picture perfect teeth whitening by written notification. In the case of an ACH transaction rejection due to (NSF), I understand picture perfect teeth whitening at it's discretion will attempt to process the charge again within 30 days and agree to an additional $20 charge for each for each attempted returned (NSF) which will be initiated as a separate transaction from the authorized recurring payments. . I acknowledge that the origination of act 1 transactions to my account must comply with provisions of U.S law. I certify that I am an authorized user of this credit/bank account and will not dispute these scheduled transactions with my bank or credit card Company; so as long as the transaction(s) correspond with the terms indicated in this authorization form.
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I understand my benefits of the 6 month membership. I receive 1 free boost pen and 10% off all products
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Purchasing this package hereby agree to all terms and conditions that apply to this package and all its parts.
***PLEASE ENTER FULL NAME HERE***
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