BHT Refund Request Form

Joint Pain Refund Request Submission Form

THIS NEW FORM WAS RELEASED AND UPDATED ON MARCH 14TH, 2024.

Patient Full Name *

Patient Phone Number Used *

Email Used For Purchase *

Original Date Of Purchase *

Payment Refund Request *

Refund Request Category *

Medical Condition Preventing Treatment *

Unforeseen Significant Life Event *

Estimated Follow Up Attempt Count *

Additional Information Explanation *

Office Email Address For Refund Confirmation *

By submitting this form, I understand and agree to these linked refund related terms and conditions. (Access Refund Related Terms By Clicking Here):

If I request a refund before 4 PM EST from Monday to Friday, it will be processed on the same day. Requests made after these hours will be processed on the next business day.
I am aware of the potential charges based on the refund reason, as outlined in our agreement. I have also recorded the patient's details and the refund reason in their contact profile.
Starting from March 14, 2024, our refund policy's terms and conditions have been made clearer to better explain the potential charges and their reasons. I agree to these updated terms.
By requesting a refund that incurs a charge, I give my consent for this transaction to be recorded for auditing purposes. I understand that by submitting this form under these conditions, I automatically forfeit the right to dispute the charge.