Summit Spine and Wellness

Chiropractic New Patient Booking

Refund Policy: To ensure the best experience for all our patients, we request 24 hours' notice if you need to cancel or reschedule your appointment. If 24 hours' notice is provided, a full refund will be issued. However, if less than 24 hours' notice is given, the payment is nonrefundable. We appreciate your understanding and cooperation.

Order Details
Description	Patient Information & Payment
Total

Contact / Shipping
Title
First Name*
Last Name*
Email*
Verify Email*
Address*
City*
State*
Zip*
Country*
Phone*
Work Phone
Birthday*

Billing Address
Copy Contact
Billing Address*
Billing City*
Billing State*
Billing Zip*
Billing Country*

Billing
Name On Card*
Credit Card Number*
Card Expiration Date*	/
Card Verification Code*	what's this?

First Name on Account*
Last Name on Account*
Bank Name*
Routing Number*	what's this?
Verify Routing Number*
Account Number*
Verify Account Number*

*Required

I authorize Summit Spine and Wellness to debit the account listed hereon $195.00, & agree to perform the issuer obligations. I affirm that the information entered on this form is true and correct and further declare that I have read, understand and accept Summit Spine and Wellness Terms as referenced in the [Terms of Use] link below.

Thank you for choosing Summit Spine and Wellness, we look forward to seeing you in the office!

| |

Summit Spine and Wellness
8151 Ridge Ave. Philadelphia, PA 19128
(217) 487-2500

To protect your client's privacy, our secure server uses secure socket layer (SSL). This ensures that the billing information is encrypted and cannot be read as this information is transferred over the internet.