North York Chiropractor | North York, ON Chiropractor

New Patient Form

Step 6 of 6

Basic Fee Schedule

Initial Chiro Exam (New patients and patients not seen in 18 months): $199

Regular chiropractic adjustment: $55- $65

Wellness care adjustment: $50

Reassessment for patients currently under care: $139

Reassessment (Patients who have not been under care 5 – 18 months): $149

I understand these fees and that a full price list is available at the front desk.

For patients above 16 years of age

Initials

Patient Signature

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Patient Name

For patients under 16 years of age:

On behalf of

I have read the above & I hereby authorize my primary Doctor of Chiropractic or such substitute as he may designate, to perform a complete spinal-neural examination and I consent to the Chiropractic care recommended, including spinal adjustment. I intend this consent to apply to all present and future care.

Dated this day of

Guardian Name

Guardian Signature

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