Monthly Agreement Form
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Full Name
*
First Name
Last Name
E-mail
*
Contact Number
*
-
Area Code
Phone Number
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
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Algeria
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Anguilla
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Fiji
Finland
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Iran
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Kenya
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Lithuania
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Maldives
Mali
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Marshall Islands
Martinique
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Mauritius
Mayotte
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Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Monthly Plan Options
*
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( X )
Adult-Monthly Chiro Plan
(
$
89.00
for each
month
)
1 adult gets four adjustments every month.
Adult- Monthly Chiro Plan w/ Exam
(
$
134.00
for the
first month
then,
$
89.00
for each
month
)
1 adult gets four adjustments every 30 days.
2-Adults- Monthly Chiro Plan w/ Exam
(
$
268.00
for the
first month
then,
$
178.00
for each
month
)
2 adults gets four adjustments each every month.
2-Adults- Monthly Chiro Plan
(
$
178.00
for each
month
)
2 adults come in 4 times a month each for only $178.
Family Plan- 2 Adults, 2 Children
(
$
301.00
for the
first month
then,
$
276.00
for each
month
)
Family of four come in 4 times a month
Adult-2 Monthly Adjustments
(
$
59.00
for each
month
)
1 adult comes in twice a month for only $59.
Adult-2 Monthly Adjustments w/ Exam
(
$
104.00
for the
first month
then,
$
59.00
for each
month
)
1 adult comes in twice a month for only $59.
2 Monthly Adjustments for Family of 2
(
$
118.00
for each
month
)
2 adults come in twice a month each for $118.
2 Monthly Adjustments for Family of 2
(
$
208.00
for the
first month
then,
$
118.00
for each
month
)
2 adults come in twice a month each for only $118 when you sign up.
Child-Monthly Chiro Plan w/ Exam
(
$
94.99
for the
first month
then,
$
49.99
for each
month
)
1 child gets four adjustments every month.
Child-Monthly Chiro Plan (17 & under)
(
$
49.99
for each
month
)
1 child gets four adjustments every month.
Monthly Fire Cupping Therapy
(
$
65.00
for each
month
)
1 adult gets 1 fire cupping therapy session every month.
Monthly Yoni Steam
(
$
150.00
for each
month
)
1 adult gets four yoni steam sessions every month.
Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Date
Postal Code
Terms & Conditions
Signature
*
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