12 WEEK HCG CARE CREDIT
12 Weeks HCG Care Credit
Subtotal: $2133 -- Discounts: $427 -- Total: $1706 -- Payment Amt: $143 -- # Payments: 12
PROGRAM INCLUDES:
LAB: 1-- Medical Provider Visit: 2 -- HCG: 12 WKS --
Appetite Medication: 6 WKS--
Lipo: 12 -- Glutathione: 12 -- Coach Visits: 12
THE FOLLOWING TERMS AND CONDITIONS SHALL APPLY to all Service Agreements between Rancho Cucamonga Medical Center (hereinafter "Provider") and(hereinafter "Client") hereby authorize R.C. Medical Center to debit the monthly agreed amounts listed to my account provided herein for my weight loss services and to adjust any over/under payment, which has been made to my accourit. ( will not hold R.C. Medical Center liable for any erroneous debits or adjustments. I agree that R.C. Medical Center will treat each debit as same as if it were personally debited by me. This remains in effect until my weight loss service agreement is paid in full. Debits /amounts will take place on the dates fisted below, if the date falls on a weekend or holiday the debit will be charged the following business day. I agree if payment declines, R.C. Medical Center will run it every day after that date in order to collect the owed amount. If payment is declined, full program cost is due and chargeable. I agree that in the event that my account becomes outstanding, I may be sent to collections and interest and/or late fees may be applied. If I am sent to collections, I understand that the $200 cancellation fee will be applied towards my overall balance owed to R.C. Medical Center.
1. All weight loss counseling weeks must be consecutive, or services will be lost.
2. Provided Client gives Provider at least one (1) week notice, Client shall be entitled to one (1) flexible week for programs or three (3) months duration, three (3) weeks for programs of six (6) months duration and six (6) flexible weeks for programs of twelve (12) months duration. A flexible week is defined as rescheduling a scheduled weekly appointment.
3. Any cancellation shall be subject to an administrative fee of $200.00. In addition, any refund shall be calculated based on the full program price without discount, prorated from the time used, and paid within thirty (30) days.
4. Any medications or injections removed from the Provider's office are not returnable or refundable.
5. Any additional medication beyond the 30 day supply is considered a booster and will be charged at $1.00 per pill.
6. Any packaged products still in original sealed container may be returned to Provider for in-store credit only.
7. Client shall be required to complete a Release of Liability form prior to removing any injection products to be administered by the Client.
8. If Client chooses to purchase any Human Chorionic Gonadotropin (HCG) product(s), Peptides, Semaglutide, or any other prescrtiptions. Client acknowledges the prescriptions are neither refundable nor returnable.
9. If Client discontinues their program, any unused products and/or services, must be used within one (1) year of Client's last visit or they expire and are nutl and void.
PLEASE ENSURE ALL SIGNATURES ARE TRUE SIGNATURES OTHERWISE IT WILL BE SENT BACK
Semaglutide Contract Consent
Patient Contract for Semaglutide Prescription
This contract is between RCMC Medical Center and the patient, regarding the supply and shipment of semaglutide. The following terms and conditions apply to this contract:
1. Supply and Shipment of Semaglutide RCMC Medical Center will supply and ship semaglutide to the patient for a period of two months or more, as prescribed by the medical provider. The patient understands that semaglutide cannot be returned or refunded due to legal and safety reasons.
2. 30-Day Moneyback Guarantee
RCMC Medical Center offers a 30-day moneyback guarantee for the program. If the patient is not satisfied with the program, they can request a refund within 30 days of the initial purchase. However, since the semaglutide prescription is being shipped for a period of two months or more, the patient understands that they will not be refunded for the prescription. The patient understands that semaglutide is $400 a month and will be responsible for the amount of semaglutide that was shipped to them.
3. Payment Plan
If the patient is on a payment plan, their payments will continue until the semaglutide prescription is paid off, even if they decide to cancel the program.
4. Responsibility for Semaglutide Prescription
The patient understands that they are responsible for the semaglutide prescription, and that it cannot be returned or refunded. They will take the medication as prescribed, and will inform their medical provider of any adverse reactions or side effects.
5. Compliance with Program Requirements
The patient will comply with all requirements of the semaglutide program, including regular check-ins with the medical provider, tracking their progress, and reporting any issues or concerns.
6. Termination of Program
If the patient decides to terminate the program before the end of their program, they understand that they will not be refunded for the semaglutide prescription. However, they can continue to use any remaining program services until the end of their program.
7. Governing Law
This contract shall be governed by and construed in accordance with the laws of the state
IT IS SIGNED IN, without giving effect to any choice of law or conflict of law provisions
8. Entire Agreement
This contract represents the entire agreement between RCMC Medical Center and the patient, and supersedes all prior or contemporaneous oral or written communications, proposals, representations, and understandings between the parties.
By signing below, I acknowledge that I have read and understood the terms and conditions of this contract, and agree to be bound by them.