Page 1 of 1
AUS Deposit Consent Form
Client Full Name:
*
Phone Number:
*
Patient Name:
*
Authorization
- If you cancel within 7 days of your scheduled ultrasound, then you will get refunded the $300.
- If not cancelled within the 7 days, then the deposit will be non-refundable.
- The $300 will be applied to the final bill at pickup.
Signature of Owner or Authorized Agent:
*
Signature
*
Submit
