Physio Patient Information Page 3

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Clinic Information
* Please Read and Sign
Office Hours
Monday
Tuesday
Wednesday
Thursday
Friday
9 – 5 pm
8 – 5 pm
9 – 5 pm
8 – 5 pm
8 – 12 pm
Pricing
PAYMENT IS DUE WHEN SERVICE IS RENDERED. Payment is accepted in the form
of cash, cheque, debit card, Mastercard and Visa.
Service
Physical Therapy
$ 110.00
(MFR, LDT, Visceral Manipulation)
*Missed Appointments*
$20.00
$20.00
Upon request, our office will be happy to print you statements to submit to your insurance
company for reimbursement.
WE DO NOT BILL SECONDARY INSURANCE
COMPANIES ON YOUR BEHALF, but we will be happy to assist you with your individual
insurance forms.
Signature
Date

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