cancellation form

We hate to see you leave. Please fill out and submit the form below to officially cancel your services with Eden House.

Name *
Name
If your pregnancy is still viable, please provide what week you are currently in of your pregnancy.
As stated in the Eden House Contract and Agreement: "There is a 50% non-refundable retainer fee due when the contract is signed. This fee ensures that we will book your estimated due date in the Eden House calendar and will be at your service. From there, we can build a payment plan for the remaining balance. The remaining balance is to be paid no later than 36 weeks. If you pay after 36 weeks, there is a $100 late fee. If you choose to cancel service before 36 weeks, you may or may not receive a partial refund. This will be considered on an individual basis. If you choose to cancel service at or after 36 weeks, the fees will not be refunded. " *
Please check the box to state your understanding of the policy above.
Electronic Signature *
Electronic Signature
I understand that checking this box constitutes a legal signature confirming that I acknowledge and understand that Eden House will be providing no further services to me and the Contract and Agreement between Eden House and myself is nullified. *