Spinal Screening Receipt

(Practice Name) (Doctor’s Name) (Address) (Address) (Telephone Number) Name: __________________________________________________________________ Address: ________________________________________________________________ Home: ________________________ Amount Paid: _______________________ Method of Payment: Cash Check Charge Exp _________ Office: ________________________ Visa/MC/Amex/Discover ________________________________ Signature:_______________________________________________________________ Appointments for Spinal Assessment: Exam Date: _____________ Report Date: ____________ Time: ____________ Time: ____________ Duration: approx. 60 minutes Duration: approx. 45 minutes (Practice Name) (Doctor’s Name) (Address) (Address) (Telephone Number) Name: __________________________________________________________________ Address: ________________________________________________________________ Amount Paid: _______________________ Method of Payment: Cash Check Charge Exp _________ Visa/MC/Amex/Discover ________________________________ Signature:_______________________________________________________________ Appointments for Spinal Assessment: Exam Date: _____________ Report Date: ____________ Time: ____________ Time: ____________ Duration: approx. 60 minutes Duration: approx. 45 minutes