Payments made by Cash, Check or CareCredit will be refunded by mail via check. We will attempt to refund any credit card on file before sending a check. Patient Full Name(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Patient IDEmail Please provide if you would like a digital copy of your refund receipt.Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Original Payment Method(Required)Please make a selectionCredit CardCheckCashOtherOther Payment MethodOriginal Payment Date (approximately) MM slash DD slash YYYY Expected Refund Due(Required)Notes Δ
