I understand that I will be issued one coupon for each treatment with all 6 treatments to be used within a 6 month period. I also understand that unused coupons will not be refunded for any reason and that expiration dates will not be extended for any reason.
Unlike other "Plans and Packages" I understand that I may transfer any of the treatments I have selected to someone else for a transfer fee of $20 per treatment if I choose to do so. Expiration dates will remain the same.
I understand that, although Balanced Health & Fitness, Inc. will do its best to accommodate my preferences (days, time of day, therapist), specific requests cannot be guaranteed.
Please read and initial each statement below verifying agreement:
"YOU PICK SIX"
Treatment Selection
Treatment #1
Treatment #2
Treatment #3
Treatment #4
Payment Information:
No statement will be sent.
Please send payment.
Send Payable To: Balanced Health & Fitness
103 E. Gregory Blvd.
Kansas City, MO 64114
Send To: Balanced Health & Fitness
103 E. Gregory Blvd.
Kansas City, MO 64114
Name On Card:
Card Type:
Card Number:
Expiration Date:
If you prefer, you may call 816-589-3030 to phone in credit card information.
*Credit card information must be provided if choosing a payment plan instead of the "Pay in Full Now" option. Your credit card will be
billed automatically and authorizations sent.
Billing Information:
Name:
Address:
City, State, Zip:
Phone:
E-Mail:
When would you like your Plan to begin:
(i.e. 09-07-09)
You Must Click The "Submit" Button To Confirm Order.
Balanced Health & Fitness
"You Pick Six"
Quick Order Form
"Solutions for Life's Balancing Act"
Comments or Questions:
Would you like to add a Pre-Paid Gratuity for each session:
The total Pre-Paid Gratuity amount will be charged to the first payment if a Payment Plan is chosen.
Treatment #5
Treatment #6
If choosing "Energy Treatment - 70 Minutes" you will get to decide when scheduling between CranioSacral, Reiki, Chan-Ri and Somato Emotional Release.
Please check your treatment entries and verify before completing the rest of the form.
Kansas City, MO 64114