Payment Agreement Form

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Select Payment Option

Option 1: One-Time Payment of total package price

Option 2: $300 deposit to secure your date

Option 3: Quoted travel fee

Option 4: Quoted travel fee and $300 deposit

Option 5: Total package fee and quoted travel fee

5

Payment Methods Currently we are accepting payments through PayPal, Venmo, Cash App and invoices.

6

Booking Fee A $300 Booking Fee is required to reserve your private post-op care Date. The $300 fee is included in your total package price. Once the deposit is made your account balance will be updated with your new remaining total.

7

Payment Agreement A deposit is mamdatory in order to reseve your dates. Upon booking of your reservation dates, payments are nonrefundable. Care to your door is asking a deposit in the amount of $300 to hold your date. The final balance will be due seven days before we travel to you. If there is to be any cancelation, we ask that you contact us emidiatly and cancel your reservation at least ten days prior to our expected travel day. Your deposit will be held for a later date, but is nonrefundable. Your dates are final upon arrival to your city and unfortunately there will be no rescheduling or changes of dates. I would like to pay according to my selected payment option. I understand and agree failure to pay all charges by the agreed payment due date may leave my post-op care date to be taking.

8

Signature

9

Date Signed

Date