Skip to document content Knowledge Hub > Forms > Financial > Student Clinic Refund Form Form Student Clinic Refund Form Clinic Refund Request Contact First NameLast NameEmail appointment booked underPhone/MobilePreviousNextDate / Time of original appointmentPlease advise the correct # sessions booked that you wish to have refundedAdultsChildASC StudentAmount paid$I have cancelled the appointment already Yes NoPreviousNext Previous Request refund