IHI ND Payment Form

IHI ND Payment Form

Please choose the option that best suits your needs
Payment Tier Selection/Billing Information

At Inside Health Institute, we believe whole-person care should be accessible to everyone. We use a simple, honor-based payment tier system to keep care accessible for everyone. We don’t bill insurance, as insurance often creates barriers to timely, personalized care. Please select the payment tier that best reflects your current circumstances. There is no income verification, and you may adjust your tier at any time if your situation changes—life happens. Those who are able to pay at higher tiers help make care available to others, supporting dignity, access, and community care. Our lowest tier for Naturopathic Medicine (ND) appointments is $60 per session, which covers the basic cost of providing services.
$180/ND Visit - I can comfortably meet my basic needs. My finances are stable, and I have adequate savings. I’m able to pay at this rate so others can access care at a lower cost.$130/ND Visit - I can meet my basic needs, and paying for therapy is not a financial hardship right now. My finances are generally stable, though they may fluctuate. I have some savings.$90/ND Visit - My basic needs are met most of thetime, but they are not always guaranteed. Paying for therapy may become burdensome to my financial well-being. My finances sometimes fluctuate. I do not have much savings. My basic needs are usually met, but not always guaranteed. Paying for ND visits may sometimes be a financial strain. My finances fluctuate, and I have limited savings.$ 60/ND Visit - I’m experiencing financial hardship, and my basic needs are not consistently being met.None of these rates fit my current situation, and I’d like to talk about other payment options.Other
Please tell us anything you would like us to know about your current financial challenges.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
If you are completing this form for a child or other dependent, what is the name of the client who will be receiving ND Care?
After submitting this form:
- After your first visit, our goal is to send you a bill via Stripe within the week.
- This will be sent to you as an email that you can pay directly online.
- You’ll be asked to add and save a payment method securely
- This allows us to bill you after each visit, based on the tier you selected
- Your card will be charged within one week of each appointment
Why We Do This

Saving a payment method helps us:
- Reduce administrative follow-up
- Keep costs lower for everyone
- Focus our time on care, not billing logistics
Your payment information is encrypted and securely stored by Stripe. We never see or store your full card details.

If your financial situation changes, your tier can be adjusted at any time.

An IHI staff member may contact you if we need to confirm or update your payment information.

Questions or billing support: 📞 425-256-2125 ✉️ info@insidehealthinstitute.org

Cancellation & No-Show Policy
- After two no-shows or cancellations with less than 24 hours’ notice, we may charge a $10 fee, regardless of your session rate.
Signature*
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IHI ND Payment Form

Payment Tier Selection/Billing Information