Request edit access
Evergreen Chiropractic Home Visit Form
Evergreen Chiropractic is proud to now be offering home visits for Infant and Pediatric CFT and Chiropractic care with Dr. Courtney. We want to have a variety of options that allow you to get the care you and your family needs in a way that feels best for you!  

Here's the cost of the services offered: 

New Patient Chiropractic Visit (45 minutes): $185 

New Patient CFT Visit (45 minutes): $185 

Follow Up Chiropractic Visit (15 minutes): $65 

Follow Up CFT Visit (30 minutes): $130

Family CFT session (1 hour 30 minutes): $360


A travel fee will also be added to all home visits once per visit. If multiple services are provided, the travel will only be added once. Here is a breakdown of the travel fees: 

Within 3 miles from the office: $20

3-10 miles from the office: $30

10-25 miles from the office: $40

25+ miles from the office: $60

If you have any questions you can text our office line at (615) 632-6226 or email drcourtneysimon@gmail.com.

Your Name *
Patient's name *
Patient's age *
Phone number *
Email *
Address for visit *
Type of visit *
Days and times that work best for you *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report