NEW PATIENT FORM

Welcome to Champion Wellness! Please fill out the New Patient Form to help us understand your health history. Your privacy is our priority, and all information will be kept secure. Download and fill out this form then submit it during your first visit!

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Chirpractic Care Services New Patient Form

DISCLAIMER: THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT OR ANY OTHER SERVICE, EXAMINATION OR TREATMENT WHICH IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OR RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION OR TREATMENT. MEDICARE AND MEDICAID ARE NOT ELIGIBLE FOR THIS OFFER AND DOES NOT APPLY TO FEDERAL OR ACN BENEFICIARIES.

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