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Credit Card Payment Policy & Agreement (Page 4/4)

Thank you for choosing the Washington Institute of Dermatologic Laser Surgery (“WIDLS”) for your dermatology and skin care needs. Please read the following information carefully prior to accepting the terms of this Agreement by signing your name in the space provided below.

In order to streamline the billing and payment system for services provided, WIDLS requests that patients provide an active credit card, debit card, HSA (Health Savings Account) card or Flex Plan Card to be placed on file for use at each visit. Your card information will be kept in a secure vault with TSYS, our payment processor, and only used for the following purposes:

  1. The card you place on file with WIDLS will be used to pay for services rendered on the day the services are rendered unless you elect to pay with cash.

  2. The card you place on file with WIDLS will be used to pay for any deposits related to services you have agreed to have rendered to you at a future date unless you pay any such deposit with cash.

  3. In the event, you have scheduled an appointment for services and you fail to show up for your appointment on time without notifying WIDLS at least 48 hours in advance of your need to cancel or reschedule your appointment, the card you place on file with WIDLS will be used to pay a fee of $250.00. If you are scheduled for a Major Procedure (CO 2 , Coolsculpting, Instalift, Thermage, Ulthera), the fee is your nonrefundable deposit of $1,000.

If your credit card is declined for any reason, we reserve the right to charge an additional $25 declined card fee.

By signing below, you consent to this Policy and indicate your understanding that you are responsible for payment of all services provided to you by WIDLS on the day of treatment. By signing below, you are authorizing WIDLS to automatically charge your card for any of the stated purposes herein. If the card you place on file changes, expires or is denied for any reason, you agree to immediately provide WIDLS with a different valid card that will henceforth be subject to the terms of this Agreement. If you agree to these terms, please indicate so by signing and dating this Agreement below.

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Washington Institute of Dermatologic Laser Surgery