Subscription/Membership Cancellation

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We’re Sorry to See You Go

Your health and recovery matter to us. Before we process your cancellation, please help us understand your reason for leaving.

Email *

Name *

Phone Number *

Which service(s) are we cancelling? *

Chiropractic Subscription

Recovery Lounge Membership

Required

Primary Reason for Cancellation (check all that apply): *

Cost concerns

Not using membership enough

Schedule conflicts

Moving / relocation

Temporary financial hardship

Health reasons

Not seeing desired results

Prefer pay-per-visit option

Found alternative recovery service

Dissatisfied with experience

Other:

Required

Would you consider returning in the future?

Yes

Maybe

Clear selection

How likely are you to recommend our Recovery Lounge to others?
(1 = Not likely, 10 = Extremely likely)

Not Likely

Extremely Likely

Clear selection

**Cancellation Acknowledgment**

I understand that:

My membership will remain active until the end of my current billing cycle.

No refunds will be issued for unused sessions unless otherwise specified in my agreement.

Any outstanding balance must be paid prior to cancellation.

**PLEASE TYPE YOUR INITIALS**

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

This form was created inside of Victory Chiropractic.

Does this form look suspicious? Report