Reservation PaymentPlease only fill out this form if you have been instructed to do so by our staff and are paying with Zelle. Please enable JavaScript in your browser to complete this form.Name *FirstLastPatient Name if DifferentEmail *Phone Number *Questions or CommentsDeposit Information: *I understand the non-refundable deposit of $1000.00 is for treatment at Esprit Wellness for myself/my daughter/my son for the following dates:Start Date month/day/year *End Date month/day/year *Terms of Service *I Have Read the Terms of Service BelowBy checking "I accept the Terms of Service below" you state that you have read and agree with the Terms & Conditions of the down payment and final payment for this treatment plan as explained above. A non-refundable payment of $1000.00 is required at the time of booking appointment time and includes a 4% Paypal user fee. This payment will be applied towards the evaluation and working up of the treatment plan. Final payment is required (due) on the day of the first visit. Your deposit will be applied to your final bill on the day of the first visit.ENFORCEMENT: APPLICABLE LAW: ATTORNEY FEES: IF it becomes necessary for Esprit Chiropractic & Physical Therapy LLC to enforce its rights under the Agreement, the Credit Authorization, and/or these Terms and Conditions, any dispute arising from such enforcement action shall be governed by state law And by the parties hereto expressly consent and agree that any dispute, controversy, legal action or other proceeding that arises under, results from, concerns or relates to this Agreement may be brought in federal and state courts and acknowledgement that they will accept service of process by registered or certified mail or equivalent directed to their last known address as determined by the other Party in accordance with this Agreement or by whatever other means are permitted by such courts. The parties hereto hereby acknowledge that said courts have jurisdiction or venue in these courts or that such courts are an inconvenient forum. I will not dispute the charges by claiming the above named individual was not authorized to use my credit card and sign on my behalf.Please enter your initials below to accept the Terms & Conditions. *By entering your initials you state that you have read and agree with the Terms & Conditions of the down payment and final payment for this treatment plan as explained above.I consent to this information being collected and stored *I AgreeNow Make Your Payment with ZellePrice: $ 1,000.00Please send payment via Zelle or from your bank.Here are the Zelle details you should know for the transfer:Zelle Name: CopyZelle Email: CopyZelle Phone: Copy I have made my payment via ZelleI confirm, my Zelle payment was successfulSubmit Your Information