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My Health Reassurance

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Last Name *

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Your E-Mail Address *

Notes to Business (your address or any special notes about your order)

Item	Quantity	Total
IV Hydration Membership-BI-WEEKLY $150	x $155.25	$155.25 every 2 weeks
Total: $155.25	Coupon:

FORMS OF PAYMENT:

CASH | CREDIT CARDS | FSA/HSA |CARECREDIT

IT IS THE RESPONSIBILITY OF THE CLIENT TO KNOW WHICH SERVICES OR PRODUCTS ARE COVERED UNDER FSA/HSA

APPOINTMENTS CANCELLED LESS THAN 24 HOURS NOTICE AND ALL NO SHOWS, WILL BE CHARGED A CANCELLATION FEE OF TOTAL AMOUNT OF VISIT

UNDER NO CIRCUMSTANCES WILL A REFUND BE ALLOWED FOR ANY SERVICES RENDERED OR PURCHASED AT MY HEALTH REASSURANCE INCLUDING BUT NOT LIMITED USING FSA OR HSA AS FORMS OF PAYMENT FOR SERVICES. CREDIT MAY BE APPLIED FOR DEPOSITS USED TO SECURE APPOINTMENT

All Memberships require a card to remain on file for the duration of the membership

-Cards will be AUTOMATICALLY charged monthly for membership service

-Unused services will not roll over to the next month

-Membership is transferable

-Membership can be canceled after 90 days and must be canceled in writing by emailing to info@myhealthreassurance.com

I Agree to the terms and conditions on myhealthreassurance.com