Patient Service Agreement
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Terms and Conditions
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All nutritional counseling weeks must be consecutive, or services will be lost.
Any medications or injections removed from the Provider’s office are neither returnable, nor refundable.
Any additional medication beyond the 30-day supply is considered a Booster and will be charged at $1.00 per pill.
Any packaged products still in original sealed container may be returned to Provider for in-office credit only.
If Patient chooses to purchase any Human Chorionic Gonadotropin (HCG) product(s), Patient acknowledges HCG is neither returnable, nor refundable.
Patient gives consent to (your clinic name here) to use name, photos, video testimony, verbal and/or written statements for local and/or national advertising use to promote their medical weight loss programs.
Provider cannot guarantee weight loss results if Patient does not follow the program as recommended.
Any weight loss package cancellation shall be subject to an administrative fee of $200.00. In addition, any refund shall be calculated based on the full retail price without any discount, prorated from the time used, and paid within thirty (30) days.
I understand I am financially responsible for all charges. I understand that should my account go to collections, I am responsible for all costs associated with collections and any costs charged by the collection company.
Maintenance program services cannot roll into the next month.
Maintenance program can canceled with a 15 day notice before next billing cycle is required. There will be a 3% merchant service feel applied to all auto draft payments.
I agree to the terms and conditions
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Date Signed
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