Prescription Deposit Account

Each one of our clients is assigned a Prescription Deposit Account upon entry into treatment. This account is utilized to cover any prescription co-payments or over this counter medication expenses that might be incurred. This account is completely separate from their Client Account funds and is ONLY used for medical expenses. Any remaining balance of this account at the conclusion of treatment will be refunded in full. Click here for information on our refund and cancellation Policies.

$ Donation Amount:

Custom Amount

Client First Name

Client Last Name

Billing Address

City

State

Zip Code

Country

Additional Notes

Select Payment Method

Authorize.Net - Credit Card
Test Donation

Personal Info

First Name *

Last Name

Email Address *

Credit Card Info

This is a secure SSL encrypted payment.

Card Number *

CVC *

Cardholder Name *

Expiration *

Donation Total: $1.00

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Prescription Deposit Account