Patient Acknowledgement

Patient Payment Acknowledgement

All professional services rendered are charged to the patient and due prior to service. You are acknowledging that you have requested medical services from Bloomble Rx, it’s partners and affiliates on behalf of yourself and understand that by making this request, you become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I understand that Bloomble Rx does not accept insurance and that fees are due and payable prior to services rendered and I personally agree to pay all such charges in full. By agreeing, you are acknowledging that you have requested these medical services and take full responsibility for all shipments made to the location of your designation for all treatments prescribed to you by Bloomble Rx and its affiliates. You understand that there are no returns and that all sales are final. In addition to agreeing to ensure a safe delivery to the address of your choosing for any treatments, you agree that you will not cancel any credit card payment to Bloomble Rx or any of its affiliates for the services you have requested. A fax, photocopy or email receipt of this agreement is to be considered as valid as the original.