Please complete this estimate only if you do not have active health insurance or are electing to not use your insurance. If you are a new client and have insurance please reach out to melanie@growwellcle.com to complete an insurance verification and begin the scheduling process. The following calculator provides a self-pay estimate based on your household size and income. Please note that this is an ESTIMATE ONLY. Name: Email Address: U.S. phone number: ( ) - Second three digits Last four digits People in household: 1 2 3 4 5 6 7 8 Please indicate how many people are in your household. Annual Household Income : Choose income More than $75,300 Between $60,240 and $75,300 Between $45,180 and $60,240 Between $30,120 and $45,180 Between $15,060 and $30,120 Less than $15,060 Answer this question: Answer the question below: = four + two