Auto Debit Application
[ ] Chiropractic Payment Plans
[ ] The Rub Club Wellness Program
[ ] Living Well for Life
[ ] Unlimited Chiropractic
Authorization Agreement for Prearranged Payments
(Debits) from Checking Account or Credit Card
I (We) hereby authorize Neighborhood Chiropractic to initiate debit entries to the credit card or bank account as indicated below and the bank or credit card company to debit such account. I understand that this authorization will remain in full force and effect until Neighborhood Chiropractic has received written notice of it’s termination in such time and such manner as to afford the opportunity to terminate this agreement.

Member Name:______________________________________________ Date: _________________
Member Address:___________________________________________________________________
City:___________________________________ ,CA Zip___________ Birthdate: _________________
Member Phone: _____________________Work: ___________________Cell: __________________
Monthly Payment Debit Date: ________(5th or 20th) Total Paid Today $______________________
Plan Details:______________________________________________________________________
[ ] Chiro Payment: Down Payment $ ______ Monthly Amount $ ________ Total Plan $ ________
Number of Deductions #: _____________ (12) Starting Date: ______________________

[ ] Rub Club: Registration Fee $ 10. Monthly Amount $ ____________ Starting Date: ___________

[ ] Living Well For Life: Monthly $___ Number of Deductions: ______ Starting Date: ___________

[ ] Unlimited Chiropractic: Monthly $99. Starting Date: _________ (12 month minimum required)
  I understand that if I cancel this program in less than 1 year my balance due will be recalculated at the regular fee per visit price. Following the 1st year this plan may be cancelled at anytime with just a 30 day notice. The cost of this plan will be decreased to $89/mo 2nd year, $79/mo 3rd year, and then $69/mo thereafter.  

Monthly Payment Debit Date: [ ] 5th or [ ] 20th
Total Paid Today$____________________
Credit Card Type: [ ] ATM [ ] Visa [ ] Mastercard [ ] Amex [ ] Discover

Credit Card #________________________________________________ Exp. _____________

I (we) wave the right to receive advance notice of the deduction associated with my membership/ doctor services and authorize a $25.00 service charge for returned unpaid drafts from the bank.
I further warrent that I (we) are the owners or authorized signers on the above referenced accounts and that I (we) have full authority to enter into this agreement.

Signature of Patient:______________________________________________ Date:_____________

Co-Signer/Guarantor if any:__________________________________ Phone:________________
Neighborhood Chiropractic 1610 150th Ave. San Leandro, CA 94578 (510)278-9702 Fax(510)278-7109