Carroll Cosmetic Club — Membership Cancellation
Carroll Cosmetic Club
Membership Services · Form MC-01
Membership Cancellation
Request

Please complete all fields to initiate your Carroll Cosmetic Club membership cancellation. Review the cancellation policy carefully before submitting — a signed copy will be retained on file.

01 Patient Information
Please enter your full name.
Please enter your date of birth.
Please enter your phone number.
02 Cancellation Details
Please enter your requested cancellation date.
Reason for Cancellation *
Please select a reason for cancellation.
03 Credit Balance & Term Status
Term Status *
Please select your term status.
04 Cancellation Policy — Please Read Carefully
  • Members may cancel at no charge after completing the full 12-month contracted term.
  • Early cancellations within the 12-month contracted period will incur a $350.00 early cancellation fee.
  • Any remaining credits must be fully redeemed before submitting a cancellation request to avoid forfeiting credits.
  • Credits may be applied toward the $350.00 cancellation fee.

If the credit balance does not cover the full fee, the member is responsible for the remaining difference.

By signing and submitting this form, I confirm that I have read and understood the Carroll Cosmetic Club cancellation policy outlined above, and I authorize the cancellation of my membership effective on the requested date.

You must acknowledge the cancellation policy to proceed.
Please enter today's date.
Electronic Signature * — Sign in the box below
Sign here with your mouse or finger
Draw your signature above using your mouse, stylus, or finger.
Please provide your signature before submitting.

By signing above, you are providing your legally binding electronic signature in accordance with the Electronic Signatures in Global and National Commerce (E-SIGN) Act.

Your information will be submitted securely to our team. We will follow up within 1–2 business days to confirm your cancellation.

✓
Request Received

Thank you for submitting your Carroll Cosmetic Club cancellation request. Your form has been securely received by our team.

We will review your information and follow up within 1–2 business days to confirm your cancellation. Please do not consider your membership cancelled until you receive written confirmation from us.

If you have any questions in the meantime, please contact us at [email protected].

Carroll Cosmetic Club · Form MC-01 · Rev. 04 / 2026
West Georgia Derm
A Division of West Georgia Dermatology