Self-Pay/Non-Covered Service Financial Agreement (Reflexology)

Financial Agreement: Reflexology Services (Self-Pay)

Document Date/Time: [document date and time]

Client Name: [client full name]

Date of Birth: [date of birth]

Clinic/Location: [clinic or location name]

Provider: [provider name or title]

Service & Cost Estimate

Service Selected: [reflexology session type and duration]

Session Price: [dollar amount]

Package Details: [package name, sessions included, total price, expiration date] (Only include if applicable; otherwise omit this field)

Total Expected Charges: [total amount for today's visit or scheduled sessions]

Estimate Assumptions: [brief inclusions/exclusions, e.g., add-ons, products, and gratuity excluded unless specified] (Keep concise)

This estimate is provided in good faith based on currently scheduled services. Actual charges may differ. This estimate is not a contract and does not obligate you to obtain services. You have the right to initiate a dispute if final charges exceed this estimate by $400 or more within 120 days of receiving the bill.

Self-Pay Election & Acknowledgment

Coverage Status (select one):

• [ ] I am uninsured
• [ ] I have insurance but am choosing not to submit a claim for this service
• [ ] I have insurance but this service is expected to be non-covered

I understand that reflexology may not be covered by insurance, and I accept full financial responsibility for the charges described above.

Payment Terms & Policies

Payment Due: [at time of service / prepayment required / per package terms]

Accepted Methods: [accepted payment methods per clinic policy]

Cancellation Policy: [cancellation window and fee, no-show fee, late arrival policy / None]

Refunds: [refund eligibility and terms / Non-refundable / Credit only]

Billing Questions: [contact phone and/or email]

If you dispute a charge, the clinic will not move the disputed amount to collections or charge late fees while the dispute is being resolved.

Acknowledgment & Signature

By signing below, I confirm that:

• I have received and reviewed the cost estimate and policies above.
• I understand this service is self-pay and/or may not be covered by insurance.
• I agree to pay the charges as described.
• I have received a copy of this signed agreement.

Client Signature: ______________________________ Date/Time: ______________

If signed by authorized representative:

Representative Name: ______________ Relationship: ______________ Signature: ______________

(If missing information prevents completing this form—such as service selection or pricing—do not proceed with signature. Defer until all required fields are complete.)

(If client declines to sign but services proceed, document refusal and obtain staff witness below.)

Staff Witness (if signature refused): ______________ Date/Time: ______________