Request for Visit Refund

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

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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
CAPTCHA