Feedback & Cancellation Request Form

As part of our cancellation process we require a written cancellation notice and a few questions to provide us with important feedback that will help us with your cancellation process. Your feedback is so important to us and we want to hear how we can better serve you in the future.

Full Name *

Email *

Why did you initially get started with a membership at EHP? *

How satisfied were you with your treatment plan? *

How informative was our staff and team of medical professionals? *

Are you aware of our Freeze option? *

What is the reason you are deciding to cancel? *

Tell us more about your experience: *

How likely are you to recommend us? *

Do you have any additional feedback you would like to share?

I understand that by cancelling my membership I will no longer have access to additional services within my membership such as complimentary check-ins, consultations or follow up lab work.

I understand that that If I were to re-enroll in a membership with Eternity Health Partners I would have to go through the initial intake process again *

I understand

We hope that you enjoyed your experience and will come back to see us soon! Thank you so much for visiting Age Management Institute, powered by Eternity Health Partners, Inc.