Consent

Financial Policy Acknowledgment & Card-on-File Authorization

Last updated: October 1, 2026

Please read and initial each section. These terms apply to every consultation, procedure, product, and membership at The Vitality & Aesthetics Institute, PLLC ("TVAAI"). The full policy is published at Deposit, Cancellation & Refund Policy.

1. Consultation deposits

Consultation deposits are non-refundable. I may reschedule with more than 24 hours' notice and my deposit will carry to the new date. If I cancel or reschedule within 24 hours, or do not attend, my deposit is forfeited. Initials

2. Procedure deposits and payment

A procedure is any service provided by a physician, or delegated to an appropriate staff member, that would effectuate a physical or physiologic change in the body to improve physical appearance, treat medical or aesthetic conditions, or attempt to restore or improve health, wellness, or appearance. Every service within or before a package, including any consultation, analysis, measurement, medication, or coordination, counts as part of that package.

Any procedure requires a 50% deposit of the total procedure price when it is scheduled. The remaining balance is due in full 24 hours before the procedure date. Initials

3. Procedure cancellations and no-shows

• Cancelled more than 7 days before the procedure: TVAAI keeps 10% of the total procedure price and refunds the rest of my deposit.
• Cancelled from 7 days to 24 hours before: no refund. A cancellation fee of 25% of the total procedure price applies, and the remaining deposit carries to a rescheduled date.
• Cancelled within 24 hours, or if I do not attend: the full 50% deposit is non-refundable and forfeited.

Example: on a $4,000 procedure the deposit is $2,000. Cancelling more than 7 days out, TVAAI keeps $400 and refunds $1,600; 7 days to 24 hours out, $1,000 is kept and $1,000 carries to a new date; within 24 hours or a no-show, the $2,000 deposit is forfeited.

If I cancel a package, any part of it already performed or provided — including a complimentary or gifted service — is billed at its full retail, non-discounted price and deducted from my deposit, in addition to the terms above. Example: a $4,000 EndoOne procedure with a $2,000 deposit, a complimentary Styku scan performed, then cancelled more than 7 days out — TVAAI keeps $400 plus the Styku retail price (for example, $50) and refunds $1,550. Initials

4. All sales are final

All sales are final and non-refundable, except as stated in Section 3. Any credit is at the discretion of clinic management. Prescription medications, including compounded medications, are billed once prescribed, when the prescription is sent to the pharmacy. From that point the pharmacy bills the Practice and the order cannot be stopped, so my prescribed medications are non-refundable even if they have not yet been compounded, shipped, or received. Initials

5. Memberships

My membership includes medical decision-making, consultation, clinic staff work, medications provided as necessary, interpretation of labs, and treatment plans. Memberships are not refundable. I may cancel with 30 days' advance notice through the patient portal, and I will be billed for the agreed-upon term that my medication covers, as agreed in my treatment plan. Initials

6. Card disputes and chargebacks

If I dispute a charge with my card issuer, I will be billed the disputed amount plus processing fees and expenses related to the dispute, charged to my card on file or sent to collections, as determined by clinic management. Initials

7. Card-on-file authorization

I authorize TVAAI, through its payment processor, to keep my payment card on file and to charge it for deposits, procedure balances, cancellation fees and forfeited deposits under this policy, recurring membership billing, and dispute-related charges under Section 6. Initials

8. Acknowledgment

I have read and understand this financial policy, I have had the opportunity to ask questions, and I agree to its terms.