lifecareforwomen.com - Pellet Payment Consent

Pellet Payment Consent
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Business Policies
Policy

Patient Consent to payment for Bioidentical Hormone Pellets:

I consent to paying for hormone pellets at Dr. Sodoma's office.
I understand that the
Female hormone pellets are
$375
and the
Male hormone pellets are
$750
This payment is non-refundable once the pellets have been ordered

By signing this consent, you understand that this payment is non-refundable once ordered:
Please sign here to consent to cancellation and liability information *

Clear
Should be Empty: