Payment For Initial Case Workup

Please only fill out this form if you have been instructed to do so by our staff.

By checking "I accept the Terms of Service below" you state that you have read and agree with the Terms & Conditions of the down payment and final payment for this treatment plan as explained above. A non-refundable payment of $1000.00 is required at the time of booking appointment time and includes a 4% Paypal user fee. This payment will be applied towards the evaluation and working up of the treatment plan. Final payment is required (due) on the day of the first visit. Your deposit for the initial case work up will be applied to your final bill on the day of the first visit.

ENFORCEMENT: APPLICABLE LAW: ATTORNEY FEES: IF it becomes necessary for Esprit Chiropractic & Physical Therapy LLC to enforce its rights under the Agreement, the Credit Authorization, and/or these Terms and Conditions, any dispute arising from such enforcement action shall be governed by state law And by the parties hereto expressly consent and agree that any dispute, controversy, legal action or other proceeding that arises under, results from, concerns or relates to this Agreement may be brought in federal and state courts and acknowledgement that they will accept service of process by registered or certified mail or equivalent directed to their last known address as determined by the other Party in accordance with this Agreement or by whatever other means are permitted by such courts. The parties hereto hereby acknowledge that said courts have jurisdiction or venue in these courts or that such courts are an inconvenient forum. I will not dispute the charges by claiming the above named individual was not authorized to use my credit card and sign on my behalf.

By entering your initials you state that you have read and agree with the Terms & Conditions of the down payment and final payment for this treatment plan as explained above.
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