SRI Terms Consent Form


You must complete this form to acknowledge your agreement and consent to Spinal Reflex Institute, Intl's Terms and Conditions for all programs, products and materials. 

Contact Information
Name *
Billing Address *
Billing Address
Shipping Address
Additional Information
Please Provide your Professional License Number
i.e. Facebook, website, internet search, article, advertisement, email, etc.
If you were referred, please provide the referrer's first & last name, if you were not, write NA
Disclaimer *
By clicking the Submit button, you are agreeing to the purchase of items from this web-site by phone or online. In accordance with Spinal Reflex Institute, International's (SRI, Intl.) Terms and Conditions, you are required to pay the full amount specified on your order summary, including all payments and interest set forth in any selected payment plan option you have chosen. Clicking the Submit button, confirms your agreement and consent to pay and is the equivalent of your signature, legal and binding. By clicking on the Submit button, you agree to the following: If I have chosen a payment plan option during this transaction, I understand and confirm that by clicking the Submit button, I am legally entering into contract for the payment plan selected, in lieu of my signature, and that I authorize SRI, Intl. to automatically charge my Visa /MC /Disc used in this transaction, the balance of payments, once monthly on the numerical day of the month of this transaction, for the specified number of payments/months and agreed amounts stated on the payment plan option I have chosen, to complete my payment plan commitment for purchase of this Spinal Reflex Institute Intl. program or product. Further that I have read, understood and agree to SRI, Intl.'s complete Privacy Policy / Terms and Conditions as outlined on this website. Click the link below or visit for our complete Terms and Conditions.