Cosmetic Procedure Refund Policy Acknowledgment Form
Please review and acknowledge the refund policy before proceeding with your cosmetic procedure.
Full Name
*
First Name
Last Name
Email Address
example@example.com
Cosmetic Procedure Refund Policy Acknowledgment Form
*
I have read and understand the Cosmetic Procedure Refund Policy. I acknowledge that I have had the opportunity to ask questions and that I agree to the terms outlined.
*
I acknowledge and accept the refund policy.
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Acknowledge
Acknowledge
Should be Empty: