Vital Tears Payment Form

Order Type



Physician


Patient


Delivery Address


Billing Address


Mobile Phlebotomy


Payment


Terms & Agreements

Patient understands and consents that Vital Tears will use the information provided in this Agreement and in the Order to provide autologous serum eye drops (ASED). Vital Tears may also use this information to conduct normal processing, payment, and healthcare operations such as, quality assessments and physician certifications. Vital Tears may also contact the patient and/or physician with regard to any current or future order(s), laboratory testing or production, and will not use this information in any other way without the patient’s express consent. The patient understands that they may revoke this consent in writing at any time, except to the extent that Vital Tears has taken action relying on this consent.

Patient understands that Vital Tears, the provider of the ASED, is not a doctor of ophthalmology or a doctor of any kind, and is not employed by, an agent of, or licensed by the patient’s physician. The patient understands and acknowledges that Vital Tears makes no warranties or representations regarding the ASED provided, and does not guarantee or certify the fitness of ASED for one’s healthcare need.

Patient Responsibility:

During ASED use, the patient agrees to remain under the care of a health care professional and to use the product only as directed by their physician. Vital Tears will not bill any insurance provider directly and will treat the patient as “self-pay” through an electronic funds transfer authorization.

Electronic Fund Transfer Authorization:

Patient or Payer hereby authorizes Vital Tears to electronically withdraw $ today from the above bank account to pay for a one time supply of Vital Tears. This authorization is for a single debit electronic funds transfer and will occur on or after today’s date.

Patient further authorizes Vital Tears to initiate electronic funds transfer authorizations to the provided account as necessary to correct any erroneous debit entries previously initiated thereto and the patient authorizes the financial institution to accept and to credit or debit the amount of such entries to patient’s account.

Patient understands and consents that Vital Tears will use the information provided in this Agreement and in the Order to provide autologous serum eye drops (ASED). Vital Tears may also use this information to conduct normal processing, payment, and healthcare operations such as, quality assessments and physician certifications. Vital Tears may also contact the patient and/or physician with regard to any current or future order(s), laboratory testing or production, and will not use this information in any other way without the patient’s express consent. The patient understands that they may revoke this consent in writing at any time, except to the extent that Vital Tears has taken action relying on this consent.

Patient understands that Vital Tears, the provider of the ASED, is not a doctor of ophthalmology or a doctor of any kind, and is not employed by, an agent of, or licensed by the patient’s physician. The patient understands and acknowledges that Vital Tears makes no warranties or representations regarding the ASED provided, and does not guarantee or certify the fitness of ASED for one’s healthcare need.

Patient Responsibility:

During ASED use, the patient agrees to remain under the care of a health care professional and to use the product only as directed by their physician. Vital Tears will not bill any insurance provider directly and will treat the patient as “self-pay” through an electronic funds transfer authorization.

Electronic Fund Transfer Authorization:

Patient or Payer hereby authorizes Vital Tears to electronically withdraw $ today from the above bank account to pay for a one time month supply of Vital Tears. This authorization is for a single debit electronic funds transfer and will occur on or after today’s date.

Patient further authorizes Vital Tears to initiate electronic funds transfer authorizations to the provided account as necessary to correct any erroneous debit entries previously initiated thereto and the patient authorizes the financial institution to accept and to credit or debit the amount of such entries to patient’s account.

Future Orders:

The patient agrees that any future, one time orders of Vital Tears for the patient will be subject to the terms of this agreement unless otherwise stated by Vital Tears. Any changes will be disclosed to the patient at the time of the new order. If desired, the patient may request Vital Tears to provide the terms of the agreement again at the time of the next order.

Patient understands and consents that Vital Tears will use the information provided in this Agreement and in the Order to provide autologous serum eye drops (ASED). Vital Tears may also use this information to conduct normal processing, payment, and healthcare operations such as, quality assessments and physician certifications. Vital Tears may also contact the patient and/or physician with regard to any current or future order(s), laboratory testing or production, and will not use this information in any other way without the patient’s express consent. The patient understands that they may revoke this consent in writing at any time, except to the extent that Vital Tears has taken action relying on this consent.

Patient understands that Vital Tears, the provider of the ASED, is not a doctor of ophthalmology or a doctor of any kind, and is not employed by, an agent of, or licensed by the patient’s physician. The patient understands and acknowledges that Vital Tears makes no warranties or representations regarding the ASED provided, and does not guarantee or certify the fitness of ASED for one’s healthcare need.

Patient Responsibility:

During ASED use, the patient agrees to remain under the care of a health care professional and to use the product only as directed by their physician. Vital Tears will not bill any insurance provider directly and will treat the patient as “self-pay” through an electronic funds transfer authorization.

Electronic Fund Transfer Authorization:

Patient or Payer hereby authorizes Vital Tears to make reoccurring monthly debit electronic funds transfers of $120 on or after today’s date. Subsequent payments will occur on this same date or after in the months following.

Patient further authorizes Vital Tears to initiate electronic funds transfer authorizations to the provided account as necessary to correct any erroneous debit entries previously initiated thereto and the patient authorizes the financial institution to accept and to credit or debit the amount of such entries to patient’s account.

Cancellation:

If patient wishes to discontinue use of Vital Tears, a request for cancellation can be made in writing to info@vitaltears.org or other written method requiring confirmation of receipt from Vital Tears. A minimum commitment and obligation of six (6) monthly payments or a combined total of $720 per order is required prior to cancellation. Cancellation of reoccurring payment may take up to 7 days to process from the date written notice is received by Vital Tears. If for any reason, the patient has not successfully paid a total of $720 they will be ineligible to re-order the Subscription Order service until the full obligation has been met.

Future Orders:

The patient agrees that any future orders of Vital Tears for the patient will be subject to the terms of this agreement unless otherwise stated by Vital Tears. Any changes will be disclosed to the patient at the time of the new order. If desired, the patient may request Vital Tears to provide the terms of the agreement again at the time of the next order.

Patient understands and consents that Vital Tears will use the information provided in this Agreement and in the Order to provide autologous serum eye drops (ASED). Vital Tears may also use this information to conduct normal processing, payment, and healthcare operations such as, quality assessments and physician certifications. Vital Tears may also contact the patient and/or physician with regard to any current or future order(s), laboratory testing or production, and will not use this information in any other way without the patient’s express consent. The patient understands that they may revoke this consent in writing at any time, except to the extent that Vital Tears has taken action relying on this consent.

Patient understands that Vital Tears, the provider of the ASED, is not a doctor of ophthalmology or a doctor of any kind, and is not employed by, an agent of, or licensed by the patient’s physician. The patient understands and acknowledges that Vital Tears makes no warranties or representations regarding the ASED provided, and does not guarantee or certify the fitness of ASED for one’s healthcare need.

Patient Responsibility:

During ASED use, the patient agrees to remain under the care of a health care professional and to use the product only as directed by their physician. Vital Tears will not bill any insurance provider directly and will treat the patient as “self-pay” through an electronic funds transfer authorization.

Electronic Fund Transfer Authorization:

Patient or Payer hereby authorizes Vital Tears to electronically withdraw $ today from the above bank account to pay for a 6 month supply of Vital Tears. This authorization is for a single debit electronic funds transfer and will occur on or after today’s date.

Patient further authorizes Vital Tears to initiate electronic funds transfer authorizations to the provided account as necessary to correct any erroneous debit entries previously initiated thereto and the patient authorizes the financial institution to accept and to credit or debit the amount of such entries to patient’s account.

Future Orders:

The patient agrees that any future orders of Vital Tears for the patient will be subject to the terms of this agreement unless otherwise stated by Vital Tears. Any changes will be disclosed to the patient at the time of the new order. If desired, the patient may request Vital Tears to provide the terms of the agreement again at the time of the next order.

Summary

Order Details

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$0.00

Delivery Address