Vital Tears Payment Form

Order Type



Physician


Patient


Delivery Address


Billing Address


Mobile Phlebotomy


Payment


Terms & Agreements

Patient agrees that they are responsible for reading and following the instructions enclosed in their Vital Tears shipment.

Electronic Fund Transfer Authorization:

Patient or Payer hereby authorizes Vital Tears to electronically withdraw $0 today from the above bank account to pay for a one time supply of Vital Tears plus an additional $20 for a one time mobile phlebotomy blood draw from the patient for 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 agrees that they are responsible for reading and following the instructions enclosed in their Vital Tears shipment.

Electronic Fund Transfer Authorization:

Patient or Payer hereby authorizes Vital Tears to electronically withdraw $0 today from the above bank account to pay for a one time month supply of Vital Tears plus an additional $20 for a one time mobile phlebotomy blood draw from the patient for 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 agrees that they are responsible for reading and following the instructions enclosed in their Vital Tears shipment.

Electronic Fund Transfer Authorization:

Patient or Payer hereby authorizes Vital Tears to make reoccurring monthly debit electronic funds transfers of $0 on or after today’s date plus an additional $20 for a one time mobile phlebotomy blood draw from the patient for Vital Tears. 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 agrees that they are responsible for reading and following the instructions enclosed in their Vital Tears shipment.

Electronic Fund Transfer Authorization:

Patient or Payer hereby authorizes Vital Tears to electronically withdraw $0 today from the above bank account to pay for a 6 month supply of Vital Tears plus an additional $20 for a one time mobile phlebotomy blood draw from the patient for 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.

Patient agrees that they are responsible for reading and following the instructions enclosed in their Vital Tears shipment.

Electronic Fund Transfer Authorization:

Patient or Payer hereby authorizes Vital Tears to electronically withdraw $0 today from the above bank account to pay for a one time mobile phlebotomy blood draw from patient for Vital Tears. This authorization is for a single debit electronic funds transfer and will occur on or after today’s date.

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.