NEW PRACTICE MEMBER FORM | V.I.B.E. ChiroWell

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V.I.B.E. - Vessels Intentionally Becoming Excellent

Tel: 336-355-6924

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NEW PRACTICE MEMBERS

Appointment Request Form
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How did you hear about us? (Please be specific so we can thank the right person!)

Are you eligible for Medicare?

V.I.B.E. Chiropractic & Wellness does not directly bill health insurance. We do accept HSA/FSA. Do you have either one of those?

Are you seeking treatment for an open, or soon to be open, Workers Comp or Motor Vehicle Accident claim?

What V.I.B.E. services are you interested in? * Required

Chiropractic

Personal Training

Health Workshops

What is the address where you want services rendered?

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North Carolina, USA

Tel: 336-355-6924

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