Website - RPA Additional Contributions Form

RPA Additional Contributions Form

Use this form to send in additional RPA contributions.
Do not use this form if you have not sent in your signed RPA Contract and your initial $500 deposit.This form is only to be used for additional contributions after you have started your RPA.
Patient Name

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
Date
Patient Email Address
example@example.com
1. Your RPA must be fully funded within 3 years. This Reversal Prepayment Contributions form must accompany each payment.
2. If you are unable to have surgery within 3 years of the signed date of your RPA contract then your RPA account will be closed and you will be refunded your money minus the $500 non-refundable administration fee. We will attempt to reach you by email and phone prior to closing your account. If we are unable to reach you when the account is scheduled to be closed, your contributions will be forfeited.
3. It is your responsibility to notify us of any changes to your email address, mailing address and/or phone number.
4. Your phone scheduling interview will need to be repeated when you are ready to schedule surgery.
5. Your complete blood count (CBC) will need to be repeated within 90 days of your surgery date. You or your health insurance will be responsible for the cost of this blood test. We recommend you take a multivitamin with iron while you are contributing to your RPA to decrease the chance you could be anemic (low iron) when you repeat the blood test.
I understand my surgery must be completed within 3 years of the signed date of the RPA contract. If surgery is not completed within 3 years then my RPA will be closed and I will be refunded my money less a $500 RPA administration fee.*

I understand
When you submit this form you will receive a link to make the actual payment through our partner Stripe.

When you initiate the ACH transfer we will receive the amount indicated above minus a $5 processing fee. The net amount that we receive will be credited to prepayment account.

We are not able to debit your account for any amount higher than your authorization.

If you see a slightly higher withdrawal on your bank statement your bank may charge an additional fee to process your ACH transfer.
Signature*

Clear
Date*

MonthDayYear
Date
Type your name in the boxes below:*

First NameMiddle NameLast Name
Intended contribution amount ($)
Product
Should be Empty: