Request for Visit Refund

If you need to request a visit refund, please submit the form below

Now virtually treating families in Colorado, Hawaii, Indiana, Iowa, Louisiana, New Jersey, New York, North Carolina, North Dakota, Tennessee, and Texas!

Request for Visit Refund Submission Form

Request for Refund

Patient Name*
First Last
Visit Date(s)*

MM/DD/YYYY
Clinic Visited*
Best Contact Phone Number*
Valid Secure Email Address (for expedited communication)*
Detailed Reason for Visit Refund Request*
Additional Requests*
Patient ID

*Internal Use Only