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, however they 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:

 All infusions must be canceled within 72 hours of your scheduled visit. No refunds can be made if you cancel within 72 hours of your visit. The visit will be payable by funds prepaid to your account or charged to your credit card on file. If for some reason payment is not made 72hrs before the infusion and cancels late, the client will have to pay for the missed visit and the new visit before rebooking another infusion.