Chirocoverage offers $50 savings for the first day with new accounts.

Be sure to call 774-526-5443 to confirm your dates.

Copy and paste this page into any word processor and fax it to 215-689-5667.

  Chirocoverage Coupon

Discount and Disclaimer * 

I understand that Dr. Powell is not a Medicare or Medicaid provider and cannot treat patients who have either form of reimbursement.  I will inform my staff to schedule patients who are covered by Medicare or Medicaid, on dates Dr. Powell is not covering the office.  

Please reserve the following date/dates:  __________________________________

Doctor’s Name: __________________________________________    (please print)  

Office Name      __________________________________________  

Street Address  __________________________________________  

City                 __________________________________________  

Phone         __________________________________________  

Office Hours    __________________________________________  

Signature ____________________________________________        Date _____________

*payment is due on last day of coverage