Telehealth Refund Request Form
Use this Telehealth Refund Request Form to submit your request for a refund related to a telehealth service. Please provide accurate details to help us process your request efficiently.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Telehealth Appointment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Telehealth Provider or Practitioner Name
*
Type of Service Received
*
Please Select
Video Consultation
Phone Consultation
Messaging/Chat Session
Prescription Service
Other
Reason for Refund Request
*
Please Select
Technical Issues
Service Not Delivered
Unsatisfactory Experience
Duplicate Charge
Other
Please provide additional details about your refund request
*
Amount Paid or Refund Amount Requested (if known)
Upload Supporting Documents (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Refund Request
Should be Empty: