Chiropractor Receipt Template
A chiropractor receipt confirms a payment after it arrives: who paid, how, for what and the balance left. This one records $674.00 paid by card for a new patient with low back pain: exam, lumbar X-rays, six adjustments and two kinds of therapy across 7 lines, balance zero. Edit it and download the PDF.
Pre-filled for a chiropractor: a new patient with low back pain: exam, lumbar x-rays, six adjustments and two kinds of therapy. Example prices: replace them with your own.
From
Granite Chiropractic
525 Market Street
Salem, MA 01970
billing@example.com
(512) 555-0125
Receipt
Received from
Dana Whitfield
14 Elm Street
Franklin, TN 37064
client@example.com
| Description | Qty | Rate | Amount |
|---|---|---|---|
| New patient exam and consultation | 1 visit | $95.00 | $95.00 |
| Lumbar X-rays, two views | 1 each | $85.00 | $85.00 |
| Spinal adjustment, 1-2 regions (CPT 98940)Lumbar and pelvic | 6 visit | $55.00 | $330.00 |
| Electrical muscle stimulation, unattended | 3 visit | $20.00 | $60.00 |
| Therapeutic ultrasound (CPT 97035) | 2 15 min | $25.00 | $50.00 |
| Lumbar support belt | 1 each | $39.00 | $39.00 |
| Reusable cold therapy pack | 1 each | $15.00 | $15.00 |
- Subtotal
- $674.00
- Total paid
- $674.00
Notes
Paid in full for a new patient with low back pain: exam, lumbar x-rays, six adjustments and two kinds of therapy. Thank you.
Paid
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Chiropractor receipt at a glance
| Amount received | $674.00 |
|---|---|
| Paid for | A new patient with low back pain: exam, lumbar X-rays, six adjustments and two kinds of therapy |
| Payment method (sample) | Card |
| Balance after payment | $0.00 |
| Receipt number | RCT-8089 |
| Lines itemised | 7 |
Lines on the chiropractor receipt
| Paid for | Amount |
|---|---|
| New patient exam and consultation × 1 visit | $95.00 |
| Lumbar X-rays, two views × 1 each | $85.00 |
| Spinal adjustment, 1-2 regions (CPT 98940) × 6 visit | $330.00 |
| Electrical muscle stimulation, unattended × 3 visit | $60.00 |
| Therapeutic ultrasound (CPT 97035) × 2 15 min | $50.00 |
| Lumbar support belt × 1 each | $39.00 |
| Reusable cold therapy pack × 1 each | $15.00 |
| Total paid | $674.00 |
| Balance due | $0.00 |
What a chiropractor receipt proves
A chiropractic receipt should list each adjustment date with the spinal regions treated, which is what HSA administrators and insurers ask for.
In the sample, Dana Whitfield paid $674.00 by card for a new patient with low back pain: exam, lumbar X-rays, six adjustments and two kinds of therapy, so the receipt shows the full amount and a zero balance.
Prepaid care plans are paid in full or in installments before the series of visits begins, usually at a discount to the single-visit price.
Recording how the customer paid
- Card: card type, last four digits and the $674.00 charged
- Bank transfer: the date the $674.00 cleared and the payer's reference
- Cash: the amount handed over and any change given
- Cheque: cheque number and bank, receipted once it clears
Avoiding chiropractor payment disputes
- Insurers that cover only active treatment often refuse maintenance visits, and patients then dispute the balance. Marking each visit as active care or maintenance on the invoice sets expectations early.
- Selling a prepaid plan and then also billing insurance for the same visits double-counts payments; the invoice should show which payer each visit is charged to.
Refunds and corrections
If part of the $674.00 is refunded, do not edit the old receipt: issue a credit note or a refund receipt that points to RCT-8089 and states the amount returned.
Frequently asked questions
How do I make a chiropractor receipt?
Enter who paid, what for and how, list the lines (or one summary line), and mark the amount paid. The sample records $674.00 paid by card for a new patient with low back pain: exam, lumbar x-rays, six adjustments and two kinds of therapy, leaving a zero balance.
What is the difference between a chiropractor invoice and a receipt?
The invoice asks for payment of the $674.00 and gives a due date; the receipt confirms the money arrived and shows how it was paid. Many customers need both for their records.
Can I give a receipt for a deposit?
Yes. Issue a receipt for the amount received now and a second one when the balance is paid, both referring to the same job.