Cancellation/Refund Requests

*Please note that requests require seven (7) business days of processing time.

Patient Name *

Date of Birth *

What type of appointment are you requesting a cancellation/refund for?

BVOA
Surgery

What was the date of this appointment?

Date

Time

How was this paid for?

Cash
Check
Credit Card
Payment Plan Options

Reason for Cancellation/Refund

By checking the box below I acknowledge the following:

1) A cancellation of a BVOA or surgical procedure can take 10 business days to be processed by our patient care team
2) During this time frame, you may still receive confirmation emails for appointments that have not yet been cancelled.
3) One of our patient care team will reach out to you to further discuss your cancellation
4) For BVOAs cancelled within 48 hours of the appointment, your BVOA fee will be retained for 1 year for you to reschedule at a time that is most convenient for you.
5) For surgery cancellations, you will be refunded for your surgical fee within 10 business days once your surgery cancellation has been processed.

I acknowledge that I have read the above