314.375.2020
BOOK AN APPT
314.375.2020
BOOK AN APPT
Cancellation Request
bvision
2020-07-13T12:51:09-06:00
Cancellation Requests
Step
1
of
4
25%
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Appointment are you requesting to cancel
BVOA
Surgery
Date of this appointment
MM slash DD slash YYYY
Please share your reason for cancelling — your feedback is very important to us as we are continuously working to improve the quality of our patient care!
*
Please indicate which other reasons apply:
Cost
Safety of eye surgery
Spouse disapproval
Customer service issue with our team
Please select which payment options you used
Cash
Check
Credit Card
Flexible payment plan - Alphaeon, zero down, 0% interest for 24 months
Flexible payment plan - Alphaeon, 60-month extended payments
Flexible payment plan - CareCredit
Flexible payment plan - GreenSky
Flexible spending account (FSA)
Health reimbursement account (HRA)
Health savings account (HSA)
Other
Indicate the amount you paid with each payment type
By checking the box below I acknowledge my understanding of the following:
1) A medical technician will reach out to you shortly to discuss your cancellation.
2) Please allow seven (7) business days of processing time for your cancellation to go through.
3) During this time frame, you may continue to receive confirmation emails for appointments for which the cancellation has not yet been processed.
*
I have read and understand the above
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