Skin Club Enrolment Form

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address

Street Address

City

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MEMBERSHIP SELECTION

CONFIRMATION

Please confirm:

I confirm that I authorise Dermaline Aesthetics to collect recurring monthly payments from my card for my membership, and that I have read and understood the full Terms & Conditions.

I consent to receiving marketing communications from Dermaline Aesthetics and agree to my data being processed in accordance with GDPR regulations.

Signature: *

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Date of Signing *

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