Online Forms

UPDATE: No Surprise ACT of 1/1/2022

Our office has established a policy to be compliant with the No Surprise Act of 1/1/2022 which allows our fees to be transparent to our patients in writing. Once we have assessed you in our consultation which is complimentary, the list below is the itemization that you are responsible to pay. Due to HIPPA, the Office of Inspector General, and the No Surprise Act 2022, our office DOES NOT allow discounts, family plans, or any installment options. If we are providers for your insurance, your insurance has negotiated its fee schedule from these prices. If you run out of benefits or if a service is not covered by your insurance, the prices below are the charges for the services without insurance. Please remember your insurance states to our office when we call, “A quote of benefits and/or authorization does not guarantee a payment or verify eligibility. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service.”

We will not know if your insurance will pay for the recommended services until the claim has been processed and an Explanation of Benefits (EOB) is sent to us. The total amount is the highest amount that we will charge.

Fees for SCCPC

Medicare Fees for SCCPC

Things to know:

Please call/text/email or use the patient portal for your appointment.  Phone: 662-423-9315   Text: 662-423-9315   Email: [email protected]

If your are calling our office,  please leave your name and phone number. We return phone calls within 24 hours.

Please note that we are a doctor's office and 'not emergency' office. If you feel that you have an emergency, call 911 or go to the emergency room.

The patient portal is available.

We are still not accepting walk-in patients due to the limited scheduling and high waiting volumes.

Sanchez Chiropractic Center, P.C. offers our patient form(s) online so they can be completed it in the convenience of your own home or office.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.
  • You can also go online to register on the patient portal. You will need an email to send a verification code in order to proceed.
  • Any questions, call 662-423-9315.
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New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Registration Forms

Download & Print Child Registration Forms

Notice of Patient Privacy Policy

Release of Private Information

Personal Injury/Car Accident Forms

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