Refund Request

We’re here to help. Please complete the form below to request a refund from Grupo Dental O2. Our team will review your submission and contact you if additional details are needed.

Important Note (Read Before Submitting)

What You’ll Need

To help us locate your account and payment quickly, please provide accurate information. If you choose ACH, you may either:

Refund amount requested *

Minimum Price: $10.00

Patient name *

Patient ID *

Phone number *

Email address *

Mailing Address *

Address Line 1

Ciudad

State / Province / Region

Postal Code

País

Office location visited *

Date of Birth *

Reason for refund request *

Refund Delivery Method

How would you like to receive your refund? *

Zelle®
ACH (Bank Transfer)

Optional (Recommended) Fields

type time Reason

Last 4 digits of card used

Preferred callback time

Required Acknowledgment / Consent

Checkboxes *

I understand refunds are processed via Zelle® or ACH only, a $25 account audit fee may apply, and processing may take 4–6 weeks.
I understand that as an insured patient, my insurance company can audit records within the statute of limitations of each state. If at any time within the permitted statute of limitations my insurance determines that there was a mistake on any payment made towards claims submitted on my behalf I will be responsible for any amount recouped by my insurance company.
I understand that I will have up to 30 days to make payments or arrangements to cover any amount recouped. I understand that failure to do so may result in Collection Efforts and reporting.