I understand that there is a $200 deposit required to schedule and hold my appointment at Northland Family Planning. I understand that this deposit will be applied to the cost of my procedure at my scheduled appointment at Northland Family Planning.
If I choose to use health insurance, I understand that this deposit will be used to cover any deductible or co-payment or any services that the insurance does not cover. In the event that any such amount is less than $200, I understand that the unused balance of the deposit will be refunded to me.
I have been advised and understand that the deposit for an appointment cancelled more than 72 hours before the scheduled appointment time will be refunded and that the refund will be processed within 10 business days of the cancellation. The deposit for an appointment canceled less than 72 hours before the scheduled appointment time will not be refunded.
I hereby authorize Northland Family Planning to charge $200 to the credit card provided for this deposit.
I understand and agree to all the above information.
Please check agree to proceed
Error! All form fields are required.
