New Practice MemberAppointment Request Name * First Name Last Name Email * Phone * (###) ### #### Reason for visit * Have you been under chiropractic care previously and if so, how long has it been since your last adjustment? * Please provide us your insurance company or will you be self-pay? * What is your availability for your first visit? Please list days of the week and times you are available. Please plan on 45 minutes for this visit. * How did you hear about our office? * Congrats! You just took the first and biggest step in your Chiropractic Journey.We can’t wait to meet you. Our current Practice Member hours are:Mondays: 9-12:30 and 2-6Wednesdays: 9-12:30 and 2-6Thursdays: 9-12:30 and 2-6.Saturdays: 10-12 (2 Saturdays per month)We will contact you shortly to set up your first appointment. To learn more about our process, check out “What to Expect”.Please note if you have commercial insurance or are self pay, we will ask for a $50.00 deposit to hold your appointment. The deposit will be put towards your services. If you do not show for your first appointment, the deposit will not be refunded. *Due to Federal Guidelines, this does not apply to Medicaid patients.We look forward to working with you to meet your Health Goals.
