CureSLIT Cancelation

1

Please enter full name

First Name

Last Name

2

Date of birth* This field is required.Please enter date of birth

Date

3

I wish to fully cancel CureSLIT* This field is required.If you wish to cancel, please stop all treatments including vials that may already be at home. I understand I am able to request canceling CureSLIT

Yes, please cancel

4

Have you been on CureSLIT for > 12 months?

YESNO

5

Cure SLIT does not cancel care with Cure Allergy ClinicI understand I can cancel CureSLIT and still continue care with Cure Allergy Clinic with other means.

I UnderstandI wish to cancel all care

6

Please select reason of cancelation* This field is required.

cost

I could not keep up with treatment

I had an issue with my delivery

The treatment did not work

Side effects

Relocation

Other

7

I understand, by canceling CureSLIT prior to completion of 3 years, I may have a return in allergy symptoms.

I Understand

8

I understand CureSLIT requires a 90 day notice, and I will still be charged for the completion of the 90 day period.

Yes, please cancel my membership