NCRegis - ESSENTIAL BLU WELLNESS

New Client Registration

We value the privacy and security of our clients information. Please know the information you provide is stored privately. securely, and confidentially. While this information is required of all new clients, and it will not be shared or sold, and it will not be utilized without prior notice. Once you complete and submit the form below, we will contact you to confirm your appointment date and time.
Thank you.

* Indicates required field

Name on Credit Card *

First

Last

Business Phone *

Personal Phone *

Type of Card *

Visa MasterCard American Express Discover

Expiration Month *

Expiration Year *

Credit Card Number *

CVC or CVV *

Billing Zip Code *

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Mailing Address (Only if different) *

Line 1

Line 2

City

State

Zip Code

Country

Service Agreement *

Cancellations: I understand and agree that a full 48-hour notice is required to reschedule or cancel. I agree and permit my credit card to be charged for the full amount of scheduled service if I fail to reschedule/cancel as agreed. Refunds: I understand and agree that there are no refunds for services rendered, pre-purchased service packages, events, products or programs. I agree and permit additional fees if payment is canceled, disrupted or disputed. Legal Liability: I understand that by checking the boxes above and submitting this form, I am agreeing to the legal and financial terms outlined in this service agreement.

eSignature *

Email *

Notes (Preferred date, time & service) *

Submit

Thank you again for choosing Essential Blu Wellness.
We look forward to serving you soon.