Thank you for choosing Holistic Origin Her Wellness. This document outlines the financial policies governing services provided by the practice.
Payment is due at the time services are rendered unless otherwise required by insurance agreements.
Patients are responsible for:
Submission of insurance does not guarantee payment.
Initial Consultation (45 Minutes)
$150
Follow-Up Visit (20 Minutes)
$75
Fees are subject to change with advance notice.
Monthly Membership:
$169/month
Minimum commitment:
3 months
Following the initial commitment period, membership automatically converts to month-to-month until cancelled.
Laboratory services are billed separately by the laboratory provider.
Patients remain responsible for understanding their insurance coverage.
Failure to attend a scheduled appointment without appropriate notice may result in fees as outlined in the Cancellation Policy.
Healthcare services already rendered are generally non-refundable.
Membership fees are non-refundable after services have been provided.
By signing below, I acknowledge that I have read and understand the Financial Policy and agree to be financially responsible for services received.
Patient Signature: _____________________
Date: _____________________