Priority Feedback Form

We apologize if you've had a poor experience with our company. We are going to prioritize this matter and reach out to you promptly!
Please provide us with some information so we can locate your account and properly review your concerns.

* Indicates Required Information

What led you to reach out to us?*

Patient First Name*

Patient Last Name*

Telephone*

Order/Invoice Number

Example: H1234567 or LH1234567

Please provide us a little information about your concerns or experience which we will investigate* Please do not include credit card information in this form.

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