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Summit Spine and Wellness

Acupuncture Appointment (New or Routine)

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.

Payment Information
Description	New Patient($120) or Routine Visit($80)
Payment Amount

Contact / Shipping
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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

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