New Patient Special

Consultation, Examination and X-rays

$50.00

Regular fee: $230.00

Some exclusions may apply, call for details.

Expires 07/30/2010

North Georgia Spinal Care, the office of Rob Buchkowski, D.C.    

650 Henderson Drive, Suite 109 Cartersville, GA 30120

As part of our New Patient Special, the consultation, examination and any needed x-rays will be provided to you for the total cost of $50.00. There is no separate charge for the evaluation of diagnostic tests or procedures. Any further treatment or services will be provided at the rates regularly charged by this office.

 I understand and agree to the terms stated above:

_________________________________________

Patient Signature

_________________________________________

Date

_________________________________________

Witness

(770) 387-2265