Secure Online Payment

Order Details
Description	New Patient Appointment Fee
Total

Contact / Shipping
First Name*
Last Name*
Email*
Address*
City*
State*
Zip*
Phone*
Birthday*

Billing Address
Copy Contact
Billing Address*
Billing City*
Billing State*
Billing Zip*
Billing Country*

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?
Verify Routing Number*
Account Number*
Verify Account Number*

*Required

I authorize Back to Health Chiropractic 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 Back to Health Chiropractic Terms as referenced in the [Terms of Use] link below.

*This fee is refundable if cancelled or re-scheduled 24 hours prior to your appointment time. Only one (1) re-schedule allowed before forfeiture of the full fee.

| |

Back to Health Chiropractic
2504 Monroe Street La Porte, IN 46350
(219) 326-5100

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.