Submit a Patient For Financial Assistance

Submit A Patient For Financial Assistance

Practice's Information

Practice's Name *

Patient Counselor / Coordinator Name: *

Practice's Phone Number

Patient's Contact Information

Patient's First Name *

Patient's Last Name *

Patient's Best Contact Phone Number *

Treatments

TREATMENT OPTION 1: Please let us know what service is being offered to the patient: *

TREATMENT OPTION 1: Recommended Price (Please quote $3,000 or higher) *

TREATMENT OPTION 1: Lowest Price Possible (Incl. All Fees and Discounts - PLEASE DO NOT DISCLOSE THIS PRICE TO PATIENTS) *

TREATMENT OPTION 2 - Is there an alternative treatment available? (optional)

TREATMENT OPTION 2 - Recommended Price (optional)

TREATMENT OPTION 2 - Lowest Price (optional)

Notes (optional)

Deposits and Payments Notes:

We offer patients the option of making a non-refundable deposit, in addition to taking loans or making cash payments as it states in our service agreement. Please accept all non-refundable deposits and payments to help cover the cost of acquisition of each patient. Treatment will commence only upon full payment according to your requirements. Patients understand that regardless of partial payments made, treatment will not begin until the full balance is paid. Patients have up to 12 months to complete full payment, after which any prior payments may be forfeited in the benefit of your practice. Please ensure Payment Terms and Refund Policies are included in the patient's sign-up documentation (For a sample, click here). This helps commit the patient to your practice and makes it much easier to engage with the patient from all standpoints (financial, follow-ups, etc).

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Financial Assistance For Patients

support@vitalismd.com

(839) 999-2535

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