Same day cancellation fee credit request form.

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Please enter a valid phone number.
3
Email* This field is required.
example@example.com
4
Appointment Date & Time* This field is required.
5
Fee Charged* This field is required.
6
Please leave all relevant details in the next section as this submission is used to make a decision.

While not all requests may be accommodated, we will review your account history to determine if you are eligible to receive a partial or full credit.
7
Reason For Request* This field is required.
Huge
Large
Normal
Small
Ok
Ok
8
I have reviewed all the policies listed and agree to the terms for future appointments.* This field is required.
Yes
9
You will be notified via text message with a final decision.* This field is required.
I Understand
Should be Empty: