HUSH MEDICAL SPA
Vitality Membership Enrollment Form
Personalized Bioidentical Hormone Optimization
Client Information
- Full Name: _________________________________
- Date of Birth: _____________________________
- Phone Number: _____________________________
- Email Address: _____________________________
- Address: _________________________________
Membership Selection
☐ Hush Vitality for Her
☐ Hush Vitality for Him
Payment Summary
- Initiation Fee: $495 (one-time)
- Monthly Membership Fee: $250/month (auto-billed)
- Initial Consultation Deposit: $50 (credited toward initiation fee)
Included Services
✓ Physician consultation & treatment planning
✓ Baseline hormone labs (CBC, CMP, lipids, hormone panel)
✓ Routine hormone prescriptions
✓ Follow-up labs every 6 months
✓ Physician check-ins & dose adjustments
✓ Unlimited messaging with Wellness Concierge
✓ Priority appointment access
✓ Exclusive member perks
Consent to Enroll
I understand the terms of the Hush Vitality Membership, including the fees, services, and auto-billing schedule. I acknowledge the $50 consultation deposit is applied toward my initiation fee if I enroll.
- Client Signature: ______________________________
- Date: ________________________________________
Payment Authorization
I authorize Hush Medical Spa to charge the payment method I provide for the initiation fee and monthly membership fee.
- Cardholder Name: _____________________________
- Billing Address: _____________________________
- Card Number (last 4 digits): ________________
- Expiration Date: _____________________________
- Signature: _________________________________
- Date: _______________________________________
Office Use Only
- Membership Start Date: __________________________
- Provider Name: _________________________________
- Notes: ________________________________________
