patient UNAPPLIED CREDIT

Patient Name

First Name

Last Name

Checkbox

Please select one of the following options.

Refund to the card that paid the initial charge

Mail a check

Please keep on file for future treatments

Transfer to a family members account

Address Correction

If you elected to have a check mailed, and your address has changed, please provide an updated address below.

Family Members Name and DOB

If you elected to have your credit transferred to a family members account, please provide their name and date of birth below

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