Lavaley Chiropractic

The Gonstead Difference

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South Burlington Plaza • 835 S Burlington Ave • Suite 106 • Hastings, NE 68901

(402) 461-1171 • Email: lavaleychiro@hotmail.com

Welcome to Our Office!

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Whom May We Thank For Referring You?

We invite you to discuss with us any questions regarding our services.  The best health services are based on a friendly, mutual understanding between provider and patient.  Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the doctor. 

 

I authorize the doctor to perform any necessary services needed during diagnosis and treatment.  I also authorize the provider to release any information required to process insurance claims.

 

I have read and agree to the above statements

 

 

Patient Signature:  AT THE OFFICE DURING YOUR VISIT

Ph:   (402) 461-1171

Fax: (402) 461-1171

E-mail: lavaleychiro@hotmail.com

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