Forms

NEW PATIENT FORMS

Intake Form:

Comprehensive Intake Form: 

Financial

We Make Optimal Health Affordable:

  • Payment is expected at time services are rendered unless a signed financial agreement has been prepared in advance with our Business Manager. Payment may be made by cash, check, Visa and Mastercard.
  • A $25.00 fee will be charged on all returned checks.
  • We do not accept insurance assignment. We will provide a completed insurance form which can be submitted to your insurance company for reimbursement. We will make every effort to comply with your insurance carrier’s requirements to obtain maximum reimbursement allowable.
  • We realize that health needs do not always coincide with financial means. When your treatment requires several visits, we will be happy to give you an estimate of the total treatment length and the approximate costs. If you have a special situation or need, please let us know and we will tailor a payment plan designed for your unique circumstances. Please speak with our business manager.
  • All supplements and supplies must be paid for in full at the time they are dispensed. This is over and above any monthly payment.
  • Personal injury cases are not accepted for assignment. You are expected to pay your fees, and collect reimbursement from your settlement.
  • Any collection costs, including but not limited to, the reasonable attorney’s fees of Wellspring Chiropractic & Acupuncture Center, arising out of, or in connection with collection of past due balances shall be borne by the patient.