Britannia Chiropractic Clinic
Prepaid Adjustments Care Program
Name:
Regular Adjustment Fee:
Date:
Diagnosis: Vertebral Subluxation
Prepaid Adjustments: 27
Program Services
It includes:
1.
A chiropractic program to help the body function and heal more effectively including specific chiropractic
adjustments at a frequency recommended by the doctor and agreed upon by you and the doctor.
2.
Recommendations and educational information to enhance your level of health and wellness. This also
includes access to therapeutic supplies, professional grade supplements, custom made orthotics, Registered
Massage Therapy, and our lending library. The cost of some of these ancillary products and services is not
included.
Fee for Services
Booking multiple appointments and paying in advance will save you time and money at each office visit. For the
Prepaid Program you will receive the benefit of a discount equivalent to three adjustment fees.
27 Adj @ $50/Adj = $ 1350
You pay: $1200
Conditions for Services
1.
If you have a motor vehicle accident or workplace accident where there will be third party payers reimbursing
the clinic for your care, your plan will be suspended until the third party payment plan is complete.
2.
One of the benefits of this plan is to minimize time required for staff to manage your account. The plan is
based on 27 distinct transactions and cannot be utilized in combination with another member at the clinic. To
this end you will receive the discount.
3.
If you, at anytime, wish to discontinue care, your adjustment visits used will be calculated at the full fee and
we will refund any remaining credit on your account.
Patient’s Acceptance
I have read and understand the terms of this agreement and elect to take advantage of the Care Program.
Name:_____________________________ Signature:___________________________ Date:__________________
Administrator:__________________________ Date:__________________