Thrivability Eligibility

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We Care Chiropractic is a 501(c)(3) charitable organization. We believe that everyone deserves access to chiropractic care and that finances should never be a barrier to experiencing its many powerful benefits. We are proud to serve underserved populations including those with low income, severe medical disabilities, and our first responders (fire heroes, police officers, military, & veterans).

Please take a few moments to complete this short form to see if you are eligible for our program. If you are eligible you will receive an email confirming so and the next steps to follow.

NOTE*

If you are a teacher or first responder you don't have to fill out the eligibility form. You just have to show a work ID, badge, or any other type of identification that proves you're a teacher or first responder.

We Care Chiropractic staff is available to assist patients in determining if they are eligible for our Sliding Fee Options. Patients MUST show the most recent proof of income for all family members/individuals living in your household; examples of acceptable documents include:

Previous year’s 1040 tax form
One month of pay stubs
1 unemployment stub
Food Stamp Award Letter
Copy of Social Security or Disability Check
Letter from an employer that states your salary or wages.

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Name* This field is required.

First Name

Last Name

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Date of Birth* This field is required.

Date

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Email* This field is required.

example@example.com

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Phone Number* This field is required.

Area Code

Phone Number

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Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Please choose one of the following reasons why you are seeking status as a client with We Care Chiropractic for chiropractic treatment* This field is required.

LOW INCOME (unemployed, disabled, fixed income)

MEDICAL DISABILITY

FIRST RESPONDER (police officer, firefighter, military, veteran)

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Please select one of the following to explain your low income status.* This field is required.

Unemployed

Disabled

Fixed Income

Other

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Please explain your answer "other."* This field is required.

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Please explain your diagnosis.* This field is required.

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Please select one of the following.* This field is required.Please present your badge or ID for verification.

Police Officer

Firefighter

Active Military

Veteran

Other

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Please state your monthly household income*.* This field is required.

*Annual Household Income is the combined earnings for one year of all adults sharing a residence.

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How many people are in your household?* This field is required.Include all adults and children living at your place of residence.

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Upload Proof of Income* This field is required.Can upload now or at your first appointment.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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You agree that all your answers are true to the best of your knowledge.* This field is required.Please sign and click submit.

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