Bodywork Registration Form

Bodywork Registration

Congratulations for taking the first step to change your health and your life.
Bodywork Benefits

Your package of service is done over a couple of visits and includes: One introductory chiropractic health evaluation, X-rays, followed by your next visit with report of findings where you also get a complimentary 15 min zero gravity chair massage.
I have read, understood, and accepted the benefits for bodywork package.
Name

First NameLast Name
E-mail
Phone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date:

MonthDayYear
Check all of the symptoms you have experienced in the past 6 months:

Neck PainHeadachesShoulder/Arm PainDizzinessProblems SleepingTingling/Numbness in the Arms or LegsBack PainLeg or Hip painLow Energy/FatigueOther
Where did you hear about us?

A Friend or colleaugeGoogleFacebookInstagramSnapchat
RULES
1. Membership is available to anyone 18 years of age or older.
2. Valid for members who live or work in the Miami Beach area.
3. You promise NOT to use to conduct any fraudulent or business activity or have more than one Member Account at any time.
4. Not available for individuals on federal programs such as Medicare or Medicaid.
Privacy Policy

(Our No Risk Office Policy) The patient and any other person is resposible for payment has the right to refuse to pay, cancel payment, or be reimbursed for payment for any other service, examination or treatment which ois performed as a result of an 72HRS of responding to the advertisement for the free service, examination or treatment.
I have read, understood, and accepted the PRIVACY POLICY for membership.
Once you submit your application, we will contact you shortly to complete your membership application and set up your first visit at our office.

Thank you!
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Bodywork Registration

Bodywork Benefits

Privacy Policy