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Acknowledgement of Payment & Cancellation

I. Payment

By my signature below, I understand, acknowledge, and agree that I am fully responsible for payment of services provided to me by Virginia Infusion Therapies and that payment must be made in full by cash, or credit card at or before the time of service.
I understand that treatment and services provided by virginia Infusion Therapies may not be covered by my insurance. Virginia Infusion Therapies does not contract with any insurance plan. Virginia Infusion Therapies will provide information to me to assist me in my claim for reimbursement to my insurance carrier, but will not submit claims to insurers on my behalf. I further acknowledge and agree that if I choose to submit any bill or itemized receipt to an insurance carrier for reimbursement for these services, that Virginia Infusion Therapies is exempt from any dispute regarding reimbursement.

II. Cancellation

To fairly and effectively serve patients who wish to receive treatment, the following cancellation policy has been implemented. By your signature below you acknowledge and agree to the following cancellation policy:

Short (Approx. 40 min) infusions must be cancelled at least 72 hours in advance. Short (Approx. 40 min) infusions cancelled at least 72 hours in advance will receive a full refund. Short (Approx. 40 min) infusions cancelled less than 72 hours in advance will incur a $325 charge, payable by funds pre-paid to your account or charged to your credit card on file.

Long (Approx. 4 hr) infusions must be cancelled at least 1 week in advance. Long (Approx. 4 hr) infusions cancelled at least 1 week in advance will receive a full refund. Long (Approx. 4 hr) infusions cancelled less than 1 week in advance will incur a $500 charge, payable by funds pre-paid to your account or charged to your credit card on file.