For every $1,000 spent with Bay Area Cosmetic Dermatology’s VIP Ship, you will earn 100 points. 100 points is equivalent to $100 towards any services in our office, excluding injectables or office visit fees. Your points won’t expire and we will keep track of your points as well as alert you each time another 100+ points has been accrued. You are welcome to check your balance at anytime by contacting VIPShip@weloveskin.com.

First Name *

Last Name *

Email Address *

Please input the address you would like to receive the products.

Shipping Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Is your billing address different from your shipping address? *

Yes

No

Billing Street Address *

Address Line 2

City *

State *

Zip Code *

CHOOSE YOUR PRODUCTS

I agree these are the products I would like to have sent to me quarterly (every 90 days). Please fill in each row with your desired product name.

Can't remember the names or prices of your favorite products?

Give us a ring (415) 292-6350

OR
Visit our web store to search our inventory.

1st Product *

Quantity of 1st Product, to be shipped every 90 days.

2nd Product

Quantity of 2nd Product, to be shipped every 90 days.

3rd Product

Quantity of 3rd Product, to be shipped every 90 days.

4th Product

Quantity of 4th Product, to be shipped every 90 days.

5th Product

Quantity of 5th Product, to be shipped every 90 days.

6th Product

Quantity of 6th Product, to be shipped every 90 days.

When would you like to receive your first shipment of products? *

Immediately (shipped priority the next business day)

3 months from today's date

PAYMENT INFORMATION

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CVV Code *

*

I authorize Bay Area Cosmetic Dermatology (BACD) to charge the account indicated above every 90 days for the payment of my quarterly VIP Ship. By signing this agreement I understand the charges associated with my quarterly shipment and that my card may be charged anytime between the 10th of the month prior to shipping month and the 20th of the shipping month.

*

I will receive free shipping and can cancel at any time. If I do not cancel, I will continue to receive the products as specified in this contract on a quarterly basis.

*

I agree to inform BACD of any change in shipping address or credit card billing information by speaking with a manager or contacting VIPShip@weloveskin.com. I agree to inform BACD if I need to adjust a shipment date or quantity by speaking with a manager or contacting VIPShip@weloveskin.com. .

*

I understand that my VIP Ship may be subject to price changes. I understand that if such changes occur, I will be notified and I will incur these charges on my authorized credit card.

*

I understand that my membership will automatically renew after a year unless I call and cancel it.

*

I understand that my VIP Ship is subject to the BACD Return Policy. The policy states: Non-Prescriptive Products can only be returned within (30) days of the initial purchase if unopened or if the patient has a reported allergy. All returned product will be converted into an office credit which can be used against future products or services. Prescription and Makeup sales are final.

*

I understand by law I am required to see a prescriber (Dr. Welsh, Dr. Austin or Dr. Kaur) for an office visit, at least once a year, in order to continue receiving prescription products. If I have not been seen in over a year, I will not be able to continue to receive any prescription products until I see a prescriber. I acknowledge any RX products in my VIP Ship will be placed on hold.

*

I authorize BACD to charge the credit card indicated in this authorization form. If the above noted payment date(s) fall on a weekend or holiday, I understand the payment will be executed on the next business day. I understand this authorization will remain in effect until I cancel it in writing and I agree to notify the business in writing of any changes in my account information, mailing address or termination of this authorization at least 15 days prior to the next billing date. I certify I am an authorized user of this credit card and I will not dispute the payments with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

SIGN BELOW & SUBMIT

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