We appreciate you choosing The District Injector for your aesthetic care. To ensure we can provide the highest quality service to all our patients, we have established the following scheduling and financial policies.
I understand and agree that The District Injector LLC requires a valid credit or debit card to be securely maintained on file in order to schedule and hold appointments. By providing my card information, I authorize The District Injector LLC to store my payment method in accordance with applicable security and privacy standards.
I expressly authorize The District Injector LLC to charge the card on file for any applicable fees, including but not limited to appointment deposits or Clinical Resource Fees, no-show fees, late cancellation fees, late arrival fees, and any outstanding balances for services rendered or products purchased.
I understand that I will be notified prior to any routine or scheduled charges; however, I acknowledge that notification may not be provided in advance for charges related to no-shows, late cancellations, late arrivals, or violations of office policies, as outlined in the applicable agreements and policies.
I further understand and agree that failure to maintain a valid card on file may result in the inability to schedule future appointments, cancellation of existing appointments, or denial of services. I acknowledge that any declined or disputed charges may result in additional fees, collection actions, or restrictions on future services at the discretion of The District Injector LLC.
By providing my card information, I confirm that I am an authorized user of the payment method and that I have read, understand, and agree to be legally bound by this policy.
To the fullest extent permitted by applicable law, I agree that I will not initiate or pursue a chargeback, payment dispute, or reversal with my credit card issuer or financial institution for any transaction for services rendered or otherwise authorized under this Agreement or the Practice’s Financial and Cancellation Policies.
I further acknowledge that initiating a chargeback or payment dispute in contradiction of this authorization, or any executed refund or release agreement, may constitute a breach of contract. In such an event, the Practice reserves the right to seek recovery of any disputed amounts, together with any associated fees, costs, and damages, to the extent permitted by law.
I understand that my credit/debit card information will be stored securely in an encrypted, PCI-compliant system. I acknowledge that I may receive notification of charges for services rendered and that no-show and late cancellation fees may be charged without additional notice in accordance with the Practice’s Cancellation Policy. I further understand that this authorization will remain in effect unless and until I provide written notice of revocation via mail or email to info@thedistrictinjector.com 30 days prior to the next scheduled payment date, and that revoking this authorization may limit my ability to schedule future appointments requiring deposits or prepayment. I agree that revocation does not relieve me of responsibility for any outstanding balances incurred prior to such notice, and I accept responsibility for maintaining accurate and current payment information on file with the Practice.
This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Virginia. If any provision is found to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.
By signing below, I certify that I am the authorized cardholder and that I have knowingly, voluntarily, and expressly agreed to the terms of this Payment Authorization, Chargeback Waiver, and Dispute Resolution Agreement, including its integration with the Practice’s Financial Agreement, Cancellation Policy, and any applicable refund or release agreements.
I understand and agree that a Non-Refundable Booking Fee is required at the time of scheduling in order to secure an appointment with The District Injector LLC. I acknowledge that the amount of this fee may vary depending on the service being booked and must be paid in full at the time of online or in-office scheduling.
I understand that the Booking Fee will be applied toward the cost of services rendered at the time of my appointment. I further acknowledge and agree that this fee is strictly non-refundable under all circumstances, with no exceptions.
I understand that if I cancel or reschedule my appointment at least seventy-two (72) hours prior to the scheduled appointment time, the Booking Fee will remain on my patient profile and may be applied toward a future appointment. I acknowledge that it is my responsibility to notify the office if I wish to apply a previously collected Booking Fee toward a rescheduled appointment. I understand that the online booking system may automatically require a new fee if I attempt to self-schedule, and that I must contact the office directly to ensure proper application of any existing fee.
I understand that any Booking Fee retained on my account will remain valid for a period of six (6) months from the original date of collection. If I fail to reschedule and utilize the fee within this six (6) month period, I acknowledge that the fee will be permanently forfeited, removed from my patient profile, and will not be eligible for refund, transfer, or credit.
By proceeding with booking, I acknowledge that I have read, understand, and agree to be legally bound by this policy.
Please include your full name, appointment date/time, and whether you wish to reschedule or cancel.
I understand and agree that all appointment changes, cancellations, or rescheduling requests must be communicated to The District Injector LLC at least seventy-two (72) business hours prior to the scheduled appointment time. Failure to provide proper notice within this timeframe will result in the forfeiture of any booking fee, Clinical Resource Fee, or deposit associated with the appointment.
I acknowledge that valid cancellation or change requests will only be accepted if communicated through the following approved methods: email to info@thedistrictinjector.com, text message to the office, or by calling 202-800-0612 and leaving a voicemail. I understand that all communications must include my full name, date of birth, and scheduled appointment date and time in order to be processed.
I further understand and agree that cancellation or change requests made through any other means, including but not limited to social media platforms, direct messages, or third-party applications, will not be accepted or considered valid notice.
I acknowledge that failure to appear for a scheduled appointment (“no-show”) without proper notice will result in the automatic forfeiture of all associated fees and will require a new booking fee or payment of service in full to reschedule future appointments.
By scheduling an appointment, I acknowledge that I have read, understand, and agree to be legally bound by this policy.
I understand and agree that appointment time at The District Injector LLC is reserved based on the total number and type of services scheduled, not on services that may or may not be performed. I acknowledge that appointment blocks are specifically allocated to accommodate all booked services and that this time is reserved exclusively for me.
I understand that if I am unable to proceed with one or more of the services scheduled, I must notify the office at least seventy-two (72) business hours prior to my appointment time so that my appointment duration may be adjusted accordingly and the unused time may be offered to another patient. Failure to provide proper notice within this timeframe will result in a cancellation fee assessed on a per-service basis for each service that is reduced, canceled, or declined.
I acknowledge that if I cancel or decline any portion of my scheduled services within seventy-two (72) business hours of my appointment, including the day of treatment, I will incur a cancellation fee for each affected service type. I understand that each service—such as neurotoxins (e.g., Botox) and dermal fillers—is considered a separate and distinct service for the purposes of scheduling and cancellation.
I understand and agree that if I present for my appointment and elect not to proceed with one or more pre-booked services, this will be treated as a late cancellation for those services, and the applicable per-service cancellation fee will be charged.
I further acknowledge that late arrivals (defined as ten (10) minutes or more past the scheduled appointment time), cancellations or rescheduling within seventy-two (72) hours, and failure to appear for a scheduled appointment (“no-show”) will result in applicable fees, with no exceptions under any circumstances, including but not limited to personal, medical, or emergency situations.
I understand that repeated cancellations, rescheduling, or no-shows may result in additional restrictions, including but not limited to the requirement to prepay in full for future services or denial of future scheduling privileges at the discretion of The District Injector LLC.
I acknowledge that any prepaid services are non-refundable if this policy is violated. If I reschedule my appointment with proper notice (greater than seventy-two (72) business hours), any prepaid amount may be applied as a credit toward a future appointment. If I fail to comply with this policy, I understand that prepaid funds may be forfeited.
By scheduling services, I acknowledge that I have read, understand, and agree to be legally bound by the terms of this policy.
I understand and agree that punctual arrival is required in order to receive scheduled services at The District Injector LLC. I acknowledge that appointment times are reserved specifically for me and that late arrival may impact the provider’s ability to safely and effectively perform the planned services.
I understand that if I arrive more than ten (10) minutes past my scheduled appointment time, I may be required to cancel and reschedule my appointment. I acknowledge that such circumstances may be treated as a late cancellation and may result in forfeiture of any applicable booking fee, Clinical Resource Fee, or deposit, as well as the application of any associated cancellation or no-show fees.
I understand that if I arrive late but the provider determines that treatment can still be performed safely within the remaining scheduled time, The District Injector will make reasonable efforts to accommodate me; however, I acknowledge that services may be modified, reduced, or declined based on time constraints and clinical judgment. I further understand that I remain financially responsible for the originally scheduled services, regardless of whether all services are completed due to my late arrival.
I acknowledge and agree that there are no exceptions to this policy, including but not limited to personal, medical, travel, or emergency-related circumstances, and that late arrival fees and associated penalties will not be waived.
By maintaining an appointment, I confirm that I have read, understand, and agree to be legally bound by this policy.
I understand and agree that The District Injector LLC maintains a strict no-refund policy. All Non-Refundable Clinical Resource Fees (also referred to as booking fees or reservation fees) are required at the time of scheduling and are non-refundable under any circumstances, including but not limited to cancellation, rescheduling outside of policy guidelines, or failure to attend a scheduled appointment. I further acknowledge that all services rendered are final and non-refundable once performed.
I understand that aesthetic and wellness treatments are not an exact science and that individual results may vary significantly from patient to patient. While providers at The District Injector will use their clinical judgment and best efforts to achieve desired outcomes, no guarantees, warranties, or assurances have been made regarding treatment results. I agree that dissatisfaction with results does not constitute negligence and does not entitle me to a refund or reimbursement.
I understand and agree that all retail product purchases are final and non-refundable. In the event that a product is determined to be defective, I may request an exchange within fourteen (14) days of purchase for the same product only, which shall be granted solely at the discretion of The District Injector LLC.
I further understand that all gift certificate and gift card purchases are final and non-refundable. Gift certificates and gift cards are non-transferable, may not be redeemed for cash, and may only be used by the original purchaser or designated recipient as determined by The District Injector.
