Dear Patient,

The Plumstead Wellness Centre provides its services directly to you, not to your insurance company.  You are ultimately liable for your bill.  If you are billing your own claims, we will provide you with an itemized bill.  However, as a courtesy to you, we will bill your insurance company for services rendered provided that your deductible has been met and you pay your co-payment at the time of service.  In the event that we are billing your insurance company and a check is mailed to you, you MUST bring the check into the office within 7 days so that we may properly credit your account. 

I hereby give my consent to The Plumstead Wellness Centre and its representatives to take X-rays as deemed appropriate by the examining Doctor of Chiropractic.  I also declare that to the best of my knowledge, I am not pregnant.

I have read and understood all the above information.

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Patient Signature                                             Date

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Witness