Statement Of Financial Responsibility Form WWNM Statement Of Financial Responsibility Form STATEMENT OF FINANCIAL RESPONSIBILITYConsentWe thank you in advance for respecting our financial and cancellation policy. I agree to pay Well Within Natural Medicine, Inc. for any and all charges for services rendered at the time of service. I understand that Well Within Natural Medicine, Inc. does not accept insurance reimbursement nor will they file insurance papers on my behalf. A receipt for services will be provided to me on request. The receipt includes services provided and does not provide diagnostic codes. If I need to cancel, I understand it is my responsibility to notify Well Within Natural Medicine, Inc. 24-hours in advance of any scheduled appointment to avoid being charged. I also understand I will be charged, by using the credit card information provided, the full fee if I do not provide a 24-hour cancellation. All consultations are by appointment only. I agree to arrive and depart all appointments at my scheduled time. I understand that a late arrival (15-minutes) or a no-show means a canceled appointment for which I am responsible for full payment. For clients within the United States, your credit card will be charged on the morning of your appointment. I agree to the privacy policy.SIGNEDDATE MM slash DD slash YYYY