PAYMENT & CANCELLATION POLICY

1. Payment

By my signature below, I understand, acknowledge, and agree that I am fully responsible for payment of services provided to me by Wes J Irwin, MD, MS, Inc (dba Tahoe Ketamine – Wellness & Infusion Center) and that payment must be made in full by credit card at or before the time of service.

I understand that treatment and services provided by Wes J Irwin, MD, MS, Inc may not be covered by my insurance. Wes J Irwin, MD, MS, Inc does not contract with any insurance plan. Wes J Irwin, MD, MS, Inc 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 Wes J Irwin, MD, MS, Inc is exempt from any dispute regarding reimbursement.

2. 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:

One hour infusions must be cancelled at least 72 hours in advance. One hour infusions canceled at least 72 hours in advance will receive a full refund. One hour infusions canceled less than 72 hours in advance will incur a $450 charge, payable by funds prepaid to your account or charged to your credit card on file.

Three or four hour infusions must be cancelled at least one week in advance. Four hour infusions canceled at least one week in advance will receive a full refund. Four hour infusions canceled less than one week in advance will incur a $800 charge, payable by funds prepaid to your account or charged to your credit card on file.

In order to respect the time of all of our patients, if you are more than 15 minutes late to your appointment, we may be unable to treat you and you will need to reschedule, incurring a $450 cancellation fee for one hour infusions or $800 for three or four hour infusions payable by funds prepaid to your account or charged to your credit card on file.