Your signature below indicates that you understand the following:  All sales are final.  You are solely responsible for any treatment rendered in this office. All services rendered to you are charged directly to you, and you are personally responsible for payment. This office does not accept insurance of any kind.  Please let us know immediately if you have Medicare.

If you purchase this entire package, a discount may be given. If the entire program isn’t completed, the discount becomes void and the items and services rendered will be charged at the standard rates, as though they had been purchased at full price a-la-carte.

If you move from the Tulsa Metropolitan area before your program is completed, we will issue a store credit up to 5 months after the purchase date. The store credit will be equal to the price charged for any services not yet rendered that were scheduled to be performed after the date of your move. The amount of the store credit for those services will be given at the rate that was originally charged. If a discount was given, the credit will reflect that. All product sales are final and no refunds or credits will be given.

When you are scheduled for a service or appointment, a room and staff member are reserved for you. If you don’t show up or are too late for us to perform the service, the staff member and room assigned to you are not utilized, and resources are wasted. Therefore, if we do not receive a 24-hour notice of cancellation for an appointment or notice that you will be late, you may still be charged for that service as if you had been here.

You authorize the staff to perform any necessary services needed during treatment. You understand that the staff is not able to offer medical advice. If you have a medical concern, please consult your medical doctor.

You understand the above information and guarantee that this form was completed correctly to the best of your knowledge and understand it is your responsibility to inform this office of any changes to the information you have provided and any changes in your medical conditions or prescriptions.

Your signature indicates that you understand these policies and that you will comply with the program that has been created for you and agreed upon. If you are non-compliant with your customized program, Synergy may put your program on hold until you comply with program guidelines. This is to ensure the long-term success of your program.

Patient Name Printed: ____________________________________________

Patient Signature:        ____________________________________________          Date:  ____________

Employee Signature:   ____________________________________________          Date:  ____________