Springfield Wellness Center

Welcome to the Springfield Wellness Center online payment system! Once you have received your payment confirmation receipt please call the office to schedule your appointment. We ask that you keep your receipt and bring with you to your appointment. Keep in mind that proper identification will also be requested upon your first visit to the office.

Springfield Wellness Center Phone Number: (217) 726-0422

Order Details
Description	New Patient Chiropractic Special
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Contact / Shipping
First Name*
Last Name*
Email*
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Address*
City*
State*
Zip*
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Phone*
Birthday*

Billing Address
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Billing Address*
Billing City*
Billing State*
Billing Zip*
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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?
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Account Number*
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*Required

I authorize Springfield Wellness Center to debit the account listed hereon $49.00, & 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 Springfield Wellness Center Terms as referenced in the [Terms of Use] link below.

Your privacy is important to us. The information you provide on this form will never be shared.

RETURN POLICY: Appointment must be scheduled within 15 days of purchase. A refund is available up to 15 days from date of purchase. If no appointment is scheduled during those 15 days the amount purchased will be forfeited.

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Springfield Wellness Center
1000 S. Durkin Springfield, IL 62704
(217) 726-0422

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.