Fettle Receipt Request Form

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INSTRUCTIONS:

Use this form to help us create a receipt with all the supplemental information that your insurer will need on file for your reimbursement claim.

Please submit one request per appointment. Be sure to use the same information (name, email, etc.) that you provided to sign up through our scheduling and payment system.

Note: This process is validated automatically. If you do not receive a receipt within 3 working days, please email ciaran@fettle.ie

WARNING:
Please ensure the date, email, therapist name and pricing plan all match the exact specifications of your original appointment or a receipt will not be issued.

First Name *

Last name *

Email *

Address *

Appointment Date *

YYYY

Appointment Type *

Payment Plan Applied to this Session *

Therapist You Worked With *

Submit

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