Credit Card Authorization Form

CREDIT CARD AUTHORIZATION FORM

Please complete all fields. You may cancel this authorization at any time by contacting The Lash Den. This authorization will remain in effect until canceled.

1 Step 1

Client Name (if different from credit card holder)

Card Type

VisaMaster CardDiscoverAMEX

Cardholder Name (as shown on card):

Card Number (please use dashes in between numbers)

CVV (three or four digit code on back of card)

Expiration Date

Billing Address

Billing Address Line 2

Billing City

Billing State

Billing Zip Code

*The Lash Den collects your CVV code only for the purpose of authorizing your credit card transaction. The Lash Den does not store or retain this information once the transaction has been authorized.

I authorize The Lash Den to charge my credit card listed above for agreed upon services that The Lash Den shall provide, subject to the cancellation policy set forth below. I understand that my information will be saved to file for future transactions on my account.

AgreeDisagree

I understand that The Lash Den has a 48-hour cancellation policy. If I do not cancel my appointment upon at least 48 hours’ notice via email, text, or telephone, The Lash Den will charge my credit card listed above for the full price of the procedure that was scheduled to be performed at my appointment (a “Cancellation Fee”); provided, however, that no Cancellation Fee shall be assessed, regardless of whether I cancel my Procedure within 48 hours of my appointment time, if such cancellation is made because (i) I am exhibiting COVID-19 symptoms, including fever, cough, shortness of breath, or loss of taste or smell (“COVID-19 Symptoms”), or I have tested positive for COVID-19 within 48 hours of my appointment; or (ii) I have been in close contact with someone who is exhibiting COVID-19 Symptoms or who has tested positive for COVID-19 within 48 hours of my appointment. Further, I agree that if I do not arrive within 15 minutes of my scheduled appointment time, The Lash Den may cancel or modify my Procedure, and I will be assessed the full price of the Procedure as originally scheduled.

AgreeDisagree

SignatureI agree to the terms and conditions

(Sign Here)

Clear Signature

Full Name

Date

If Client is a minor under the age of 18:

SignatureI agree to the terms and conditions

(Parent or Guardian's Signature)

Clear Signature

Full Name

Date

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