FINANCIAL ARRANGEMENTS - Non-Insurance
We feel the patient’s health needs are paramount, therefore, the following payment plans are an attempt to allow the patient to receive the care he or she needs at a payment they can afford.
Payment at the time services is rendered. Initial office visits range from $125 - $250 depending on the complexity. Existing patients visits range from $55 to $165. Specialty procedures including hormone pellets and injection therapies vary and will be discussed with the patient individually.
Prepay - 5:5 office visits for acupuncture $325.00 and receive a $50.00 savings.
Prepay - 10:10 office visits for acupuncture $555.00 and receive $200.00 savings.
*If other therapy or modalities are necessary, additional charges will apply.
For your convenience our office is equipped to accept cash, check, Debit Card, Visa, or MasterCard.
Packages are valid for one (1) year from date of purchase.
This certifies that I have read and received a copy of the above information and agree to all of these terms.
Initials______
INFORMED CONSENT TO MEDICAL CARE
I request and consent to the performance of physical examination, acupuncture, biopuncture, injection therapy and other medical procedures including various modes of hormone therapy, nutritional therapy, herbal therapy, pharmeceuticals and necessary diagnostic labwork on myself (or on the patient named below, for whom I am legally responsible) by Dr. Marie Niechwiadowicz, NMD a licensed primary care physician and specialist in the state of Arizona.
I understand that the results of treatment are not guaranteed. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, although very rare, including but not limited to bruising, edema, allergic, reactions and possible severe unforeseeable complications. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time based on the facts then known, is in my best interest. This consent form covers the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. This consent shall remain in force until revoked by me in writing.
We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.
Signature ______
Print Name______
Date______
Evidence Based Integrative Medicine
Dr. Marie Niechwiadowicz, NMD
1000 E Camelback Rd.
Phoenix, AZ 85014 602-279-7376