Consent to Treatment Elevate MedSpa Membership Agreement Client Name (“Client”): ________________________________ Membership Starting Date (“Start Date”): ________________________________ Birthday: ________________________________ Starting Tier (select one): Glow Smooth Lift This Subscription Agreement (the "Agreement") is made and entered into as of the Start Date, by and between Elevate Medical Spa PLLC d/b/a Elevate MedSpa (“Elevate MedSpa”) and Client. Subscription Term. By signing this Agreement, Client subscribes to the Elevate MedSpa Membership Program (the "Program") for an initial twelve (12) month initial term (the “Initial Term”), commencing on the Start Date. Client shall pay to Elevate MedSpa, a monthly subscription fee in the amount indicated in Section 4 for the Tier that they select. Elevate MedSpa may terminate this Agreement immediately if Client breaches any term of this Agreement. Payment. Client agrees to make monthly payments via recurring electronic charges as indicated in the Payment Authorization Form. Flexible Tiers. Client will have the option to choose from one of the tiers selected above to start and described further herein. Client will have the option to move between tiers during the Initial Term, with a base tier starting with the Glow package (described below). If Client wishes to move from a higher tier to a lower tier, Client shall give notice of moving to a lower tier at least 5 days prior to the numeric renewal day indicated on their Start Date. If the numeric day indicated on the Start Date is on the 29th, 30th, or 31st, then the renewal date shall be on the last day of the month that it lands. For example, if a Start Date is on January 31, the next renewal day is on February 28. Tier Benefits. Client shall receive the benefits associated with their Selected Tier as described below. Elevate MedSpa reserves the right to add benefits at their discretion. Glow: One (1) monthly facial (For example: Dermaplane, chemical peel, lymphatic drainage with gua sha) Ten percent (10%) off all skincare products. One dollar ($1) off per unit of neurotoxins. Access to Exclusive member-only promotions and events. Smooth: One (1) monthly facial, including those offered under the Glow tier, as well as Dermaplane Deluxe or DiamondGlow. One (1) quarterly Tox treatment (20 units per session). One dollar ($1) off per unit of neurotoxins for additional injectables. Fifteen percent (15%) off all skincare products and laser treatments. Priority booking for neurotoxin and skincare services. Lift: One (1) monthly facial, including those offered under the Glow tier, as well as Dermaplane Deluxe or DiamondGlow. One (1) monthly skin tightening treatment (Laser or SkinPen microneedling). One (1) quarterly Tox treatment (20 units per session). Fifteen percent (15%) off additional injectables, skincare products, and laser treatments. Access to VIP event invitations and early access to new treatments. Tier Pricing. The tiers are priced as follows: Glow: $79 / month Smooth: $179 / month Lift: $279 / month Tier pricing is subject to change at renewal. Additional Services with Each Tier. Client will also receive the following services, without charge, regardless of the tier. Machine skin analysis for each treatment ($150+ value) ‘Add on’ your birthday month ($50+ value) Annual facial tier booster voucher ($120+ value) Additional Facials. If, in a membership month, Client desires an additional facial service, Client may purchase additional facials at the corresponding membership tier price per session described in Section 5. No Freeze or Holds. Client may not “freeze” or “hold” their membership. Application of Other Funds. Account credits and gift cards may not be applied to a membership. These may, however, be applied to add ons and additional products or services. Manufacturer Coupons. Manufacturer coupons may be applied towards the purchase of future purchase of products, services, and add ons. Client can combine manufacturer discounts, such as Alle points (used with Allergan DiamondGlow and Botox promotions) and Evolus (used with Jeuveau promotions). If more than 20 units are used in a monthly period under the Smooth and Lift packages, or if Client has the Glow package, Clients may use manufacturer coupons applied directly to the incremental amounts used. Rollover. Up to three (3) unused monthly services may be rolled over to subsequent months so long as a membership is active. Rolled-over services expire three (3) months after the date they were issued. During each calendar month, Elevate MedSpa will use the current month’s services first before using any rollover services. Gifting. Client may gift or assign their monthly facial included in the Selected Tier may be gifted to friends or family. Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the State of Minnesota. Entire Agreement. This Agreement constitutes the entire understanding between the parties solely related to the purchase of products and services described herein and supersedes all prior negotiations and agreements, whether written or oral. This does not, however, supercede other applicable informed consents and notices required for Elevate MedSpa to continue to provide services. SIGNATURE DATE Payment Authorization Form I ____________________________ authorize Elevate MedSpa to charge my credit card or debit card or using the information indicated below for payment of services, subscription, additional services, missed appointments, or any other payments legally owed by me at Elevate MedSpa. Billing Address____________________________ Phone# ______________________ City, State, Zip ____________________________ Email ______________________ ☐ Visa ☐ MasterCard ☐ Amex Cardholder Name _________________________ Account Number _________________________ Exp. Date _________________________ I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Elevate MedSpa in writing of any changes in my account information or termination of this authorization. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form. SIGNATURE DATE _____ I, the client, acknowledge and agree to the terms provided by Elevate Medical Spa PLLC DBA Elevate MedSpa (“Elevate Medical Spa PLLC DBA Elevate MedSpa”, “us”, “Company”, “MedSpa”). The number of sessions required to achieve satisfactory results will be determined by Elevate MedSpa at its sole discretion. In the event that additional services are required beyond the package invoice quantity, the client is responsible for purchasing additional services. This guarantee is subject to the terms and conditions outlined by Elevate MedSpa. This package does not guarantee a specific result. Additional Terms and Conditions Promotional Period: Clients may purchase packages within the promotional period as described on the advertisement or invoice. New Clients: Promotions are exclusively available to new clients. Maximum 2 Packages per Client: Each client is limited to purchasing a maximum of two packages. Booking Period: Clients must book within 45 days of purchase. Treatment Sessions: Clients must use the services outlined in their invoice within a full calendar year starting from the time of purchase. Medical Director's Discretion: The timing and frequency of treatments are at the discretion of the medical director. Promotion Eligibility: The promotion is offered at the discretion of the medical director. Individuals with a medical contraindication to services are not eligible to receive the promotion. Promotion termination: The promotion is subject to end at any time. Package Expiry: Each package expires one year from the date of purchase. Refund, Cancellation, and Transfer Credit Policy In the event of cancellation, any discounts (e.g. monthly specials) and credits obtained through the promotion will be forfeited. Refunds are determined based on the treatments received at the standard individual price, not on the remaining sessions. A prorated refund is calculated by subtracting the total standard individual session price of the treatments received from the promotional price. This prorated amount can either be refunded or applied towards a new treatment package. Disclaimers No refund will be issued if desired results are not achieved after completing sessions. No refund will be issued in the event of an adverse event. Results may vary, and NO RESULT IS GUARANTEED. The risks associated with the procedure will be explained at the time of purchasing the package and signing the agreement. Our goal is to manage expectations and minimize the risk of adverse events. Other Fees No-Show Fee: $20 – Charged if you fail to attend your scheduled appointment. Cancellation Fee: $20 – Charged if you cancel your appointment without providing at least 24-hour notice. Shaving Fee: $20 – Charged if you arrive for your appointment without shaving, unless instructed otherwise to photograph treatment efficacy. By signing this consent form, I, the client, acknowledge that my payment covers the procedures performed during the agreement period as described in the invoice and does not guarantee any specific results. By signing this consent form, I, the client, acknowledge that I have read, understood, and agreed to all the terms, conditions, and information it contains. I acknowledge that I have received a copy of this signed agreement form from my healthcare provider. Please contact us if you have further questions: [email protected] / 763 – 342 – 0427