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Office Visit

Do you need an appointment?
This package includes the office visit with a physician or one of our highly trained advanced practice providers, and an xray if needed. This xray applies to only one body area and the office visit applies to only one problem area.

Does not include:

CT Scans or MRI
Durable Medical Equipment (boots, splints, braces, crutches, etc.)
Injections or aspirations
Any subsequent services
If a fracture is diagnosed, there will be additional charges beyond what is collected today.

$305.00

Patient Name

DOB (mm/dd/yyyy)

Direct Pay Service

I acknowledge this direct pay service will not be filed with my insurance and cannot be filed at a later date.

Refund Policy

I will not be refunded if services are rendered. However, I acknowledge I will be refunded if my provider does not agree with the plan of care and services are not rendered.

Business Day Delay

If payment made after hours, on the weekend or holiday, your payment may not be posted to your account until the next business day. Please show your emailed receipt at your upcoming appointment.

Qty

Description

Does not include:

CT Scans or MRI
Durable Medical Equipment (boots, splints, braces, crutches, etc.)
Injections or aspirations
Any subsequent services
If a fracture is diagnosed, there will be additional charges beyond what is collected today.

Additional Info