Office Agreement with David Delaney - David Delaney, Certified Advanced Rolfer®, Boulder County, Colorado 303-449-2004 david@daviddelaney-rolfing.com

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CC on file and agree to paid with less than 48 hours notice to David Delaney at 303-815-3160 voice message (no texting accepted for cancellations)

Office Agreement: please Initial*
This agreement is with David Delaney for services on a per session basis. Current fee for a session with David is discounted at $185 with cash/check ($195 charged to the credit or debit card). I can also choose to pay by check or cash at the time of the appointment. As per cancellation agreement, this agreement authorizes David Delaney (Delaney Training Solutions) in the event that I miss a scheduled appointment, or I have provided the office with less that 48 hours cancellation notice (call 303-815-3160 to cancel), as I have agreed, I authorize payment for that missed appointment on my credit/debit card (Mastercard, Visa, American Express, Discover). This policy is for the sole purpose of maintaining a balance in our relationship because I ask David to put aside time for me in advance.
Name*
First Last
Date*
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Phone*
Home Phone
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Consent*
I accept and comply with this Office Agreement
Signature*
Credit Care Type*
Name as appears on Credit/Debit Card*
Credit/Debit Card #*
Credit/Debit Card Expiration Date*
Verification Code (on back of card)*
Billing Address ZIP Code*
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