Number of Adults. Number of Children under 18: Premier Care $49/mo: Number of Adults: Number of Children under 18: Signature Care $129/mo: Number of Adults: Number of Children under 18: Signature Family Plan $229/mo for two adults in same household: Add child under 18 for $19/mo Non-Member $60/administration fee per visit Self-pay patient (no admin fee) *With the non-member option, you are agreeing to pay this fee at the time of service in addition to any copays, if necessary. With this option, you will receive Main Care benefits for 7 days after your visit. Anything beyond 7 days after your visit may warrant a follow-up, in-person visit. Primary Doctor: Billing Information: Name on Card: Card #: Expiration: CVV: Signature: I would like to pay for the year in full at the discounted rate. I, , hereby agree to the terms of the option(s) selected above and detailed in this agreement (reverse side). I authorize Institute of Complementary Medicine, to deduct the cost of that option from the account named herein upon signup, and thereafter on the first (1st) of each month, unless otherwise stipulated in writing. I understand that I may cancel the service at any time with written notice. I understand that this agreement does not replace my insurance and that I am responsible for any copays, co-insurance and deductibles that may apply outside of my membership choice. This monthly fee is not billable to insurance. Signature Date: Practical solutions for better health. Institute of Complementary Medicine 0000 X Xxxxxxxxx Xxxxxx, Xxxxx 000 | Xxxxxxx, XX 00000 | 206.726.0034 | 000.000.0000 fax xxx.xxxxxxxxxx.xxx
Number of Adults. Number and Age of Children …………………………………............. Are any cots required? Y/N (tick as appropriate) Number Required ………………………............ Do you require us to book any activities on your behalf? Y/N (tick as appropriate) Do you require airport transfers? Y/N (tick as appropriate) Total Occupancy Fee: R 50% DEPOSIT R (payable within one week)) 50% BALANCE R DUE BY Please note that signing the booking form serves as confirmation that you have read and accepted our Terms and Conditions (attached to this form). Client Signature: ………………………….....………..... Date: …………………………………................... PLEASE FAX COMPLETED FORM TO + 00 (0) 00 000 0000 or + 00 (0) 00 000 0000 or SEND BY EMAIL TO xxxxxx@xxxxxxxxxxx.xx.xx TERMS and CONDITONS • Rates are subject to change without prior notice • All rates are quoted per night from 3pm to 11am daily • All rooms are to be vacated by 11am on day of departure • A discretionary surcharge is levied on single night stays (in high and peak seasons) • A deposit of 50% of the total accommodation cost plus any activities to be added is required upon confirmation of booking. Proof of payment for the deposit and our booking form (including confirmed flight details and anticipated arrival time) should be completed and returned to us within a week of confirming a booking • The balance payable is due a month prior to arrival for international bookings and a week prior to arrival for domestic bookings • Payment should be made as a fixed rand amount with all charges payable by sender • Payment can be made by EFT or credit card (a surcharge may be levied on amounts over R5,000 paid by credit card) • We reserve the right to retain deposits received if bookings are cancelled at any stage or still unpaid within one month of the arrival date • In the event of early departure, the full extent of the confirmed booking cost will still be required • For cancellations made : From date of confirmed booking to 120 days before commencement of services: 20% total quoted accommodation price forfeited 119 days to 90 days before commencement of services: 30% total quoted accommodation price forfeited 89 days to 60 days before commencement of services: 40% total quoted accommodation price forfeited 59 days to 30 days before commencement of services: 50% total quoted accommodation price forfeited 29 days to commencement of services: 100% total quoted accommodation price forfeited • If any breakages or damage occur, guests are expected to notify us immediately ...
Number of Adults. 2 Number of Children: 0 Your Rental Deposit is due upon signing of Short Term Rental Agreement in the amount of $200.00 Rental rate and fees are as follows: Rental Rate of $120.00 x # night $ State and Local Sales/Rental Tax (16.75%) $Cleaning Fee $150.00$ Rental Deposit $<200.00> Total Amount Due 48 hours Before Arrival Date $ Please sign and return the attached lease agreement along with your reservation deposit. The balance of the rental amount is due one (1) days before your arrival date. When the total amount due is received, we will send instructions on how to access the property. All payments are made through SQUARE ( link is on the website) Signature of Responsible Party Date: Sincerely, Rose’s House, LLC Short Term Lease Agreement Checklist Prior to Arrival: □ Signed and dated agreement □ Rental deposit □ Balance due □ Keys and access information Arrival: □ Check-in time: 11AM, unless approved earlier at least 48 hrs. in advance □ Go through inspection checklist □ Review rental rules and regulations Departure: □ Check-out time: 2PM, unless approved later at least 48 hrs. in advance □ Go through inspection checklist □ Return keys □ Return security deposit Inspection Checklist: Arrival Departure N/A Notes Good Good Good A/C Heater Lights Floors Walls Doors Windows Window treatments Screens Locks Fireplace Kitchen Refrigerator Oven Stove Dishwasher Garbage Disposal Bathrooms Bedrooms Living Room Dining Room Washer/Dryer Garage Backyard/Patio Guest acknowledges that he/she has inspected the Property and unless otherwise noted, everything is in good repair. Any damages upon departure shall be charged to Guest or deducted from the security Deposit.
Number of Adults. Number and Age of Children …………………………………................................................. Are any cots required? Y/N (tick as appropriate) Number Required ………………..........………............ Do you require us to book any activities on your behalf? Y/N (tick as appropriate) Do you require airport transfers? Y/N (tick as appropriate) Do you have any dietary requirements? ...................................................................................................................................
Number of Adults. Maximum of 6
