WP E-Signature by Approve Me - Sign Documents Using WordPress -

Payment & Cancellation Policy

ketamine infusions lake tahoe

I. 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 or cash 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 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.

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:

IV Hydration Therapy infusions must be canceled at least 72 hours in advance. IV hydration therapy infusions canceled at least 72 hours in advance will receive a full refund. IV hydration therapy infusions canceled less than 72 hours in advance will incur a $199 charge, payable by funds prepaid to your account, or charged to your credit card.

One hour Ketamine infusions must be canceled at least 72 hours in advance. One hour ketamine infusions canceled at least 72 hours in advance will receive a full refund. One hour ketamine 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.

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

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 $199 cancellation fee for IV Hydration Therapy, a $450 cancellation fee for one-hour ketamine infusions, or $800 for three or four-hour ketamine infusions payable by funds prepaid to your account or charged to your credit card.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

April 12, 2020 3:08 pm PDT

Payment & Cancellation Policy Uploaded by Tahoe Ketamine - [email protected] IP 47.33.63.230