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Refund Request Submission Form

THIS NEW FORM WAS RELEASED AND UPDATED ON FEBRUARY 6TH, 2024.

Patient Full Name *
Patient Phone Number Used *
Email Used For Purchase *
Original Date Of Purchase *

Payment Refund Request *
   
   
   
   
 * $37 Platinum Package (Full $37 Refund)
 * $164 Diamond Package (Full $164 Refund)
 * $127 Diamond Package Upgrade (Partial Refund)
   
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Refund Information **Information submitted here will determine if you may or may
not be charged for this refund so please make sure to include as many details as
possible.*
Office Email Address To CC When Refund Has Been Processed *

I agree that refunds requested before 4PM EST Monday-Friday will be processed
the same day; outside these hours, they will be processed the next business day.
By submitting this form, I acknowledge potential charges as per our agreement's
terms and conditions based on the provided refund reason. I also confirm that
patient notes and refund reasons have been added to their contact profile.

Submit Refund Request

(This action can not be undone)