Todays Date: June 13, 2026
Member Name:
Phone Number:
Email Address:
By sharing your reason for cancellation, you help us identify areas to grow and serve our clients better:
Membership Type:
Membership Start Date:
As stated in our Membership Agreement our cancellation policy asks for 10 days written notice before your membership cancellation. If the date signed is less then 10 days before the end of the month your membership cancellation will be the following month from the date signed.
Requested Cancellation Date:
Please choose the last day of the month that you would like to be charged. Ex. 11/30/24 would mean your last auto billing would be on 11/1/24.
Terms and Conditions of Membership Cancellation:
- Early Termination Fee: If your cancellation request is before your one year membership start date, an early termination fee will apply:
- Gold Membership: $295
- Platinum Membership: $575
For Office Use Only
Membership/Plan ID: ____________________________
Membership Start Date: ____ / ____ / ____
Membership End Date: ____ / ____ / ____
Cancellation Processed By: ____________________________
Final Confirmation: By signing below, I confirm my request to cancel my Skinlogic Med Spa membership as of the specified date and agree to the terms and conditions listed above.
