B12 Payment

Integrity Family Practice

B12 Cyanocobalamin 30ml
I authorize Integrity Family Practice to charge my credit card in the amount of $120. This includes the Medical Evaluation, Prescription, and delivery of B12 Cyanocobalamin 30ml. I fully understand that if for any reason this prescription can not be fulfilled I will be returned the full amount of payment.

I likewise certify that I am the authorized user of the Credit Card that shall be submitted through this form. As long as the transactions correspond to the terms and conditions indicated in this authorization, I shall not raise disputes against Integrity Medical Weight Loss. Once a prescription is ordered there are no refunds. No exceptions.
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B12 Cyanocobalamin 30ml$0.01
This includes the Medical Evaluation, Prescription, delivery of 30ml B12 Cyanocobalamin (30 week supply), and 30 1ml subcutaneous syringes.

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Integrity Family Practice