Scoliosis Activity Suit Payment

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Terms & Conditions

I/we have been informed (explained) of the cost of the SAS, and any other fees that may be needed to complete the visit in advance. I/we have also been informed of the amount of follow up visits and the cost for each visit. I/we understand that follow up visits are mandatory every 3 months throughout the entire period. I am fully aware that Esprit Chiropractic, Physical Therapy & Acupuncture, PLLC, does not accept insurance. Today’s fitting visit is $1400 plus a 4% Paypal user fee . Payment is due the day services are rendered in full (today). I/we understand that payment is required at the time of service and no refunds will be issued once the patient leaves our office with the SAS for any reason. I/we understand that once the SAS is custom fitted and worn, we cannot return it for any reason. Should the SAS not be an effective treatment, due to the nature of scoliosis and its potential for other related musculo-skeletal conditions, I/we understand that we cannot return the SAS for any refunds, regardless of any changes the patient may incur as a result of the SAS. 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. I/ we have read, reviewed, understand and agree to the policies of Esprit Chiropractic, Physical Therapy & Acupuncture, PLLC, and the content contained in this agreement

Agreement:

Please enter your initials below to accept the Terms & Conditions.

I Agree

By entering your initials you state that you have read and agree with the Terms & Conditions as explained above.