Fee & Payment Agreement template

1. Fees

• Session / Service RateText
• Frequency of BillingText

• Fees for services are set out below and may be reviewed periodically, with at least 30 days' notice of any change given in writing.

2. Payment Method and Timing

• Payment is due at the time of booking or within 14 days of invoice, by the method agreed with the Provider (card, bank transfer, or other agreed method).

3. Late Payment

• Invoices unpaid after 14 days may incur a reasonable administrative charge and may result in suspension of future appointments until the account is settled.

4. Refunds

• Fees for services already delivered are non-refundable. Fees for undelivered services will be refunded or credited in accordance with the Provider's cancellation policy.

5. Insurance and Third-Party Payers

• Where fees are covered in whole or part by insurance or a third party, I remain personally responsible for any shortfall or unpaid portion.

Client Information

• Full NameText
• Billing AddressText
• PhoneText
• EmailText

Provider Information

• Provider NameText
• Registration No.Text

Signatures

• Client SignatureSignature
• Date signed (client)Date
• Provider SignatureSignature
• Date signed (provider)Date