Dinner Sign-Up

dropshadow

Join us for a FREE dinner at Broccolini's in Madison. Presented by doctors and staff. This fun and informative dinner presentation will answer your questions and give you the opportunity to learn about Total Health and receive a health pass for a FREE exam, consultation, medical history and 2 FREE X-Rays* (if medically necessary).

 

First Name: **
Last Name: **
Address: **
City: **
State: **
Zip: **
Email: **
Home Phone: **

Phone calls are returned between 6pm to 9pm, Monday through Thursday please be sure that we have an evening phone number.

Work Phone:
Age: **
Place of Employment:
Employment Status:
Full Time
Part Time
Unemployed
Comments:
                             (** REQUIRED ENTRY)

Normal price: Exam, Consultation, Medical history = $180.00
Two X-rays (if medically necessary) = $70.00.
Total: $250.00
Price with HEALTHPASS = $0.00
*This offer void to those on Medicare. Federal regulations prohibit free services to be offered to Medicare recipients.