Testosterone Replacement Therapy Program
I understand that I am enrolling in the Testosterone Replacement Therapy (TRT) Program offered by New You Weight Loss & Wellness Center.
The monthly fee for this program is $229.00 per month, which includes the services and medications outlined by my healthcare provider.
Automatic Payment Authorization
I hereby authorize New You Weight Loss & Wellness Center to initiate recurring electronic withdrawals (ACH debits) from my designated checking or savings account for the monthly amount of $229.00.
I understand that:
· The payment will be automatically withdrawn each month on or about the same date of my enrollment.
· I am responsible for ensuring sufficient funds are available in my account.
· Returned payments, insufficient funds, or declined transactions may result in additional fees and/or interruption of treatment.
· This authorization shall remain in effect until properly canceled in accordance with this agreement.
Cancellation Policy
I understand that participation in the TRT program is ongoing unless canceled.
To discontinue treatment and stop future automatic payments, I must provide written notice at least thirty (30) days prior to my next scheduled payment date.
Written cancellation requests may be submitted by:
Email: newyouweight@gmail.com
Mail or In-Person Delivery:
New You Weight Loss & Wellness Center
206 Rembert C Dennis Blvd
Moncks Corner, SC
I understand that failure to provide a minimum of thirty (30) days written notice may result in one additional monthly payment being processed.
Authorization to Charge Outstanding Balances
I authorize New You Weight Loss & Wellness Center to charge my designated account for any unpaid balances related to TRT services, medications, supplies, laboratory fees, or other authorized charges incurred under my treatment plan.
Revocation of Authorization
I understand that I may revoke this authorization by providing written notice to New You Weight Loss & Wellness Center. Revocation of payment authorization does not eliminate my responsibility for any charges incurred prior to the effective cancellation date.
Treatment Eligibility and Fee Changes
I understand that enrollment in the Testosterone Replacement Therapy (TRT) Program is subject to ongoing medical evaluation and approval by the healthcare providers of New You Weight Loss & Wellness Center. The provider reserves the right to modify, suspend, or discontinue treatment if it is determined that TRT is no longer medically appropriate, safe, or beneficial for me.
I understand that the monthly program fee is currently $229.00 per month. New You Weight Loss & Wellness Center reserves the right to adjust program fees, medication costs, or related charges. In the event of a fee increase, I will be provided with at least thirty (30) days written notice prior to the effective date of the change.
Continued participation in the TRT program after the effective date of any fee change shall constitute acceptance of the revised fee schedule. If I do not agree to the revised fees, I may cancel my participation in the program by providing the required thirty (30) days written notice as outlined in this agreement
Laboratory Testing and Additional Services
I understand that the monthly TRT program fee of $229.00 covers only those services, medications, and supplies specifically included in my treatment plan. Certain services may require additional charges, including but not limited to:
· Laboratory testing and blood work
· Diagnostic testing
· Additional office visits beyond those included in the program
· Specialist consultations
· Medications, supplies, or services not included in the standard TRT program
I acknowledge that periodic laboratory testing is required to monitor the safety and effectiveness of Testosterone Replacement Therapy and may be required before treatment initiation and throughout treatment. I understand that I am financially responsible for any laboratory testing, follow-up evaluations, or additional services not specifically included in the monthly TRT program fee.
I authorize New You Weight Loss & Wellness Center to charge my authorized payment method for approved services, laboratory fees, or balances due that are not covered by my monthly TRT program fee, unless alternative payment arrangements have been made in advance.
Patient Acknowledgment
By signing below, I acknowledge that:
· I have read and understand this Automatic Payment Authorization and Treatment Agreement.
· I voluntarily authorize recurring monthly withdrawals of $229.00.
· I understand the 30-day written cancellation requirement.
· I have had the opportunity to ask questions regarding this agreement.
· I agree to comply with all program policies and payment terms.