🛑 Payment Dispute / Charge Inquiry Form

If you believe there was an issue with your payment (e.g., duplicate charge, incorrect amount), please fill out this form completely and accurately.

All fields are required unless stated otherwise. Incomplete or inaccurate submissions may not be processed.

Disputes are reviewed within 3–5 business days. You will be notified of the outcome via SMS and/or email.

Please enter your full name. Enter a valid email address. Phone number is required. Reference is required. Please describe the issue. Please select the visit date. Please select your visit time. Please select your payment method. Accepted formats: JPG, PNG Max 5MB. The file will be encoded before sending. File format must be JPG or PNG.
Please provide your signature above.

Please confirm to proceed.