Cost Per Visit: $450
and includes the following:
1.) Initial Evaluation - approximately 30 min appointment
2.) One pair of bilateral custom orthotics
3.) Three follow-up appointments within one year of the initial evaluation
By signing below, I attest that I meet the requirements to participate in the Patient Self Pay. The contents of this form have been explained to me, and I have voluntarily signed this agreement before receiving the described services. I have been told what the estimated costs will be. I agree to pay for the services in full or within the guidelines of a formally established payment plan between myself and the Provider.