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As of 2019, we are in network providers with Medicare only. We are no longer in network with major medical insurance. However, you can take advantage of our discounted rates, provided the payment is made on the day the treatment is rendered (a.k.a. time-of-service). Oftentimes, these rates are actually lower than your in network rates. If you would like us to check your Medicare information before your scheduled appointment, please submit your information in the comments box or call with the information at least two business days ahead of your appointment.

Patients Name*

Name

Email*

Phone*

Date of Birth*

Date of Last Visit*

Are you having any flu-like symptoms?*

COVID pre-screening questions for the saftey of patients and staff

Yes
No

Have you traveled outside of the Greater Houston area in the past month?*

COVID pre-screening questions for the saftey of patients and staff

Yes
No

Have you been in contact with anyone that has COVID-19 or tested positive for COVID-19?*

COVID pre-screening questions for the saftey of patients and staff

Yes
No

If you answered yes to any of the COVID pre-screening questions, have you self-quarantined for 14 days?*

Yes
No
N/A

Type of service you are requesting*

Reason for Visit*

Doctor or Provider you'd like to see*

Message/Comments*

West University Wellness - Houston, TX

Chiropractic

Acupuncture

Massage Therapy

Pregnancy

Pediatrics

Post-Partum

Sports Injuries

Nutritional Counseling

Reiki Energy Work

Restorative Yoga

Lymphatic Drainage

Dry Needling

Telehealth

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