Subscription Cancellation/Change Request Form

Subscription Cancellation/Change Request Form

Please fill out this form to request cancellation or a refund. Have your details ready, including your consultation date and provider information if applicable.
What would you like to request?
Full Name of Customer

First NameLast Name
Email
example@example.com
New subscription tier plan requested (type N/A if not applicable)
Name of Licensed Provider (if known)
Date of Initial Consultation

MonthDayYear
Date
If requesting a refund, were you determined by a licensed provider during your initial consultation to be NOT eligible to commence GLP-1 or peptide therapy?
If requesting a refund, has GLP-1 therapy been prescribed or ordered for you?
Please provide any additional information or comments regarding your request.
Refund Disclosure: Refunds are only available if you were determined ineligible by a licensed provider during your initial consultation and GLP-1 therapy has not been prescribed or ordered. (information will be confirmed). All cancellations are subject to a $30 administrative fee.
Cancellation Disclosure: If you choose to cancel your subscription, your subscription will be canceled effective the next billing date.
I consent to Virtual WeightCare charging (or crediting) my payment card on file based on the published pricing of the new tier plan selected, and I understand the fee will be prorated upon request to reflect new pricing. (allow 1-2 days for most requests). Choose 1 option below:
Patient signature
Date of Request

MonthDayYear
Date
Should be Empty: