602 954-2447
PhoenixChiropractor.com

Dr. Anthony Montoya

Personal Information
Occupation & Employment
Chiropractic History
Automobile Accident
Reason for Visit & Symptoms

Click on the spine or shoulder areas where you feel pain or discomfort. Selected areas will be included in the form submission.

Spine pain area selector
No areas selected — click the spine or shoulder areas on the diagram above
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Health History \— Past 6 Months

Check any of the following you have experienced in the last six months:

Payment Policy
Due to changes in health insurance fees, patient self billing has become a much more cost effective way for you, the patient, to get reimbursement for your care. Self billing allows us to keep our fees low so you can get the care you need without any added cost. Therefore, our policy is that all payment is due at the time of service and bills will no longer be sent to your insurance provider. Statements will be provided for individuals to submit their own bills ensuring that as your insurance provider pays for your care, they will send the reimbursement check directly to you.

All charges are due when services are rendered.

Authorization & Signature

I authorize this Chiropractic Office to provide me necessary services and accept responsibility for all charges incurred.

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