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Refund Request
Step
1
of
2
50%
Name
(Required)
First
Last
Email
(Required)
Please select the reason for your refund request.
(Required)
I purchased an initial consultation and attempted to reschedule that appointment, but there were no appointments available.
I was meaning to cancel my membership but didn't do so in time.
I purchased a membership but there are no appointments available.
I paid for an appointment when I am a member and should have used a membership credit to book an appointment
I purchased 4 appointments instead of purchasing a membership
It's for another reason that is not listed.
You are requesting a refund because you attempted to reschedule an initial consultation, but there were no appointment slots available.
You are requesting a refund because you canceled your membership but you were still charged for it.
You are requesting a refund because you purchased a membership but there are no appointment slots available.
You are requesting a refund because you paid for an appointment when you are a member and should have used membership credits to book your appointment.
You are requesting a refund because you purchased 4 appointments instead of purchasing a membership.
You are requesting a refund for other reasons.
What is/was the date of your initial consultation?
(Required)
Month
Day
Year
What is/was the time of your initial consultation?
(Required)
Hours
:
Minutes
AM
PM
AM/PM
What was the date your membership renewed?
(Required)
Month
Day
Year
What is the date your membership was purchased?
(Required)
Month
Day
Year
What did you pay in total for 4 appointments?
(Required)
What did you pay for your membership?
(Required)
How many appointments did you pay for instead of using appointment credits?
(Required)
What did you pay for each appointment?
(Required)
Have you canceled your appointment?
(Required)
Yes, I have canceled my appointment.
No, I have not canceled my appointment.
Have you canceled your membership?
(Required)
Yes, I have canceled my membership.
No, I have not canceled my membership.
Do you have any scheduled appointments?
(Required)
Yes, I have appointments scheduled.
No, I do not have any scheduled appointments.
Have you since purchased a membership?
(Required)
Yes, I have now purchased a membership.
No, I have not purchased a membership.
Select which of the following applies to you:
(Required)
I have canceled all of my upcoming appointments
I have canceled some of my upcoming appointments
I did not cancel any of my upcoming appointments
I know definitely that I do not have any upcoming appointments
Did you miss the deadline for canceling your appointments?
(Required)
Yes, I missed the deadline.
No, I did not miss the deadline.
I understand that if I did not receive confirmation...
(Required)
I understand that if I did not receive confirmation that an appointment was canceled, then it probably wasn't.
Please provide any other explanation or reason for your refund request here. (optional)
Please explain in detail why you are requesting a refund.
(Required)
What is the refund amount that you're requesting?
(Required)
Name
This field is for validation purposes and should be left unchanged.
