Country Chiropractic & Wellness Center, P.A. - Where illness ends and healing begins...
Forms/New Patient Paperwork
In order to keep our prices low and provide you the best care possible, WE DO NOT FILE OR ACCEPT ANY INSURANCE, INCLUDING MEDICARE OR MEDICAID

We do not accept assignments from attorney's, or participate in Workers Comp or Personal Injury cases. 

Payment is required at the time of service. We will give you a receipt for your records.

Depending on your health issues, your first office visit will be approximately 20-30 minutes with the doctor. If your visit exceeds 40 minutes you may incur additional charges based on $40 per 10 minutes. Your initial visit, for non-Prolozone issues, will require a minimum $95 investment ($90 for the visit and $5 for a one day Tribal pass). The $5 fee for the one day pass may be applied toward an annual membership ($35) within the first 30 days. The first visit must be paid in full by either a credit/debit card, Health Savings/Flex Spending Account Card (must have a Visa or Master Card Logo), or cash. If you are seeking Prolozone, or Ozone treatments, your first visit will be the cost of the treatment plus the required $5 Tribal pass. 

(What is the Tribal Pass? We are a Tribal Facility, meaning we are licensed by a Tribal entity as part of their TED (Tribal Economic Development) program. As a Tribal Facility, the tribe allows non-Native Americans to be treated in their facilities by offering the member pass. All the pass fees and a percentage of all monies collected in this clinic go to support the tribes that license us.) If you are a tribal member please show your tribal ID and the member fees are waived.

Prolozone Prices:

Shoulder, Knee, Ankle, Foot, etc.      $185 each area
Spine                                                     $385 per area
Trigger Points                                      $65 up to 5 spots
Scars                                                     $15 per inch
Manipulation w/Prolozone                  $25
PRP/Stem Cell w/Prolozone                $350

NO CHECKS are accepted for payment on the first visit.
Forms #1 and #2 are required of everyone. 
Only fill out form #3 if you are needing labwork, or wishing to be treated for Thyroid or Adrenal issues.
Please answer ALL questions completely and accurately. 
Please use Black or Dark Blue ink Only, Thank you.