Vive Family Chiropractic

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Description	Shockwave Discount Package Set of 9
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Are you a current patient of Vive? (If not there will be an additional cost for a short exam)
What area of your body is your concern? (We do NOT treat over the spine, during pregnancy or children whose growth plates are still open)
Confirm that you will not be using NSAIDS , steroids , or blood thinners 48 hours before and after treatment.
Disclaimer: This tool does not provide medical advice. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read here or anywhere online. If you think you may have a medical emergency, immediately call your doctor or dial 911.

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I authorize Vive Family Chiropractic to debit the account listed hereon $720.00, & 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 Vive Family Chiropractic Terms as referenced in the [Terms of Use] link below.

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Vive Family Chiropractic
102 S Wilson Ave Jefferson, IA 50129
(515) 386-2976

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