Financial Hardship Application
We'll never turn away a patient needing help, making good health choices and is committed to feeling better. Complete this application to see if you qualify for care at COOR Wellness under our Financial Hardship Program.
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Email *
Your Name *
What are you needing help with? *
If you're needing help getting out of pain, what specific area(s) need help?
How did you first hear about COOR Wellness?
Do you use tobacco?
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Do you use alcohol?
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Do you use recreational marijuana?
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Do you have any non-healthy habits that cost money?
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If you answered 'yes' to any of the tobacco/alcohol/marijuana/health habits question, please outline your useage?
If you answered 'yes' to any of the tobacco/alcohol/marijuana/health habits question, are you eager to discontinue?
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What more can you tell us that will help us serve you?
What do you believe is your monthly budget for wellness services at COOR Wellness?
If you're unable to pay full self-pay rates for chiropractic care, are you willing and able to barter products or services that may benefit COOR Wellness?
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If you're wanting to barter products or service, what do you think you can provide that's helpful to COOR Wellness?
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