19420 N. 59th Ave., Ste. E-515
Glendale, AZ 85308
Thank you for joining our Wellness Program
Our agreement with you: You are agreeing to receive a monthly massage, which will be paid for via an automatic
monthly draft, based on the information you provide to us at the bottom of this form. This program also entitles you to
receive additional massages during the month at your wellness membership rate as well as the ability to
purchase in studio gift cards at that same low rate. Unused massage sessions roll over each month. There
may be additional benefits of membership as well. Please check with the Client Service Specialist for more information.
This membership may be shared with ONE additional person as an Associate Member (may be a family member or
significant other) and he/she will receive the same benefits as the member.
Initials: __________
Member Name: __________________________________________ Membership Start date: __________________
Associate Member Name: _____________________________________________
Cancellation policy: If you need to cancel for any reason we ask that you kindly complete our Wellness Program
cancellation form. There is no fee to cancel, but we do require 30 days notice. During those 30 days, you have
the opportunity to use any of your massages or convert each pre-paid session to an in studio gift certificate for a $10 fee.
Initials: __________
Select your optimal health & wellness choice:
 55 minute massage ($59 per month)
 80 minute massage ($89 per month)
 110 minute massage ($119 per month)
 55 minute hot stone massage ($79 per month)
 80 minute hot stone massage ($109 per month)
Select payment type
Credit or Debit Card:
 Visa  MasterCard  Discover
American Express
Card Number: ___________________________________________
Expiration Date: _______________
Name of cardholder if different from member name: ______________________________________________
Restrictions: Not valid with any other offer; valid only at this location; massage appointments must be cancelled with
a 24 hour notice to avoid charges; this is an individual membership but may be shared with ONE additional person.
By signing below I agree to the wellness program and payment type selected above. I authorize Elements Therapeutic Massage® of
Glendale, AZ to charge or ACH my transactions from the above referenced account. I understand that this authority will remain in
effect until the proper procedures are followed to cancel my membership. (See cancellation policy referenced above.) In the event of failed
payment, Elements Massage has the right to immediately terminate my membership resulting in forfeiture of any unused sessions.
Client Signature: _________________________________________________ Today’s Date: __________________