Consultation Consent Form
The purpose of the follow-up consultation is to discuss your
progress, provide counselling on changes you can make to your diet and
lifestyle, and determine modifications to your herbal formula. Please note that this is a consult only and
does not include an acupuncture treatment
Follow up phone/Vide/in-person consultations require on average 15
to 30 minutes. The fee for a follow up consult is $85.00 including GST.
Please fill out the credit card information below and we
will mail the consult receipt along with your credit card slip.
Credit
Card Processing Information
I, hereby
authorize Acubalance Wellness Centre, to charge the following credit card
account below for consultation and herbal and/or shipping fees as stated above.
Credit
Card Information (Please Print)
Card Number:
PIN Number (Last 3 digits on back of credit card)
Expiration Date: Card Type: Visa Mastercard
Name on Card:
Billing Address:
Street/ P.O
City Province
Postal Code
Fax Number (optional):
Signature: Date:
Printer-friendly version
