Active Health Chiropractic Center
Dr. Bridget Owens, Chiropractor
402 Superior Av., Tomah, WI  54660
www.drbridgetowens.com                            608-374-3000

These special plans are offered to those who have special financial circumstances including those without insurance, those who have an insurance plan that does not cover Chiropractic or have a large deductible.

You may opt to pay each visit and pay full fees for your adjustments and all other services, or you may choose one of our Package Plans.

Due to federal laws, practice members covered by Medicare and its substitutes are not eligible for these plans.

Wellness Package ~ Pay for 4 office visits @ $30 in advance/must schedule 1 per week
Total Due=$120  ($60 savings)

Bronze Package ~ Pay for 12 office visits capped @ $40 in advance
Total Due = $480  ($60 savings)

Silver Package ~ Pay for 25 visits capped @ $40 in advance includes 1 re-exam
Total Due=$1000  ($125 savings + exam)

Gold Package ~ Pay for 50 office visits capped @ $50 in advance includes 2 re-exams
Total Due=$2000  ($250 savings + 2 exams)

Additional Benefits of Plan:
* Family members may share plan

Terms and conditions:
* 1 year expiration

I have read and agree to the terms and conditions listed above.  I understand that if I do not choose a Package Plan, I am required to pay for each visit in full at the time of service.

__________   Payment options:  in full with cash, check, credit/debit 

__________   I choose the following Package Plan (circle one)   BRONZE  SILVER  GOLD  WELLNESS

_________     I will pay for the visit with the understanding that I may purchase a plan at any time in the    
                       future.

NAME__________________________________(PRINT)

SIGNED_________________________________________________DATE_______________