Terms of Service and Cancellation Policy Notice

First Name:

Last Name:

Email:

Phone:

I understand that weekly fee includes the weekly appointment but is not dependent of that visit. The Weekly fees are charge per week regardless of my attendance to my weekly appointment.

I also understand the fees to be:

• an initial fee of 349
• and thereafter, $100 per week for the length of my membership

(Initial)

Cancellation Policy:

Lifelong Balance has no contract requirements and is a weekly program. We do require you to notify us no less than 5 business days prior to your desire to cancel your membership to allow adequate time for cancellation and to incur no further charges on your credit card.

(Initial)

All membership cancellations must be made in writing and emailed to drsusan@lifelongbalance.net.

(Initial)

Date: