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Schedule a Chiropractic Appointment

To schedule an appointment, complete the form below:
This information will be kept confidential and will be only used to schedule
your appointment with the best doctor for your symptoms, location and health benefits.

Name:		Street Address:
City, State, Zip:		Home Phone:
Work Phone:		Cell / Pager:
E-Mail:		Occupation:
		Age:

Injury History	Auto Accidents/Fender Benders	Year Describe
	Work Related	Year Describe
	Fall or Other	Year Describe
	Back Surgeries Past or Future	Year Describe

Symptoms	Headaches or Migraines	Sinus Problems
Check all that apply	TMJ (Jaw Pain or Popping)	Neck Pain
	Shoulder Tension	Carpal Tunnel Pain
	Pain between Shoulder Blades	Low or Mid Back Pain
	Hip Pain
	Arm, Hand, Fingers, Wrists, Elbows		Pain Numbness Tingling Left Side Right Side
	Legs, Feet, Toes, Arches, Calves, Knees, Thighs		Pain Numbness Tingling Cramps Left Side Right Side
	Describe which symptoms bother you most.
	How long have you had it?
	How often do you feel it? Constant Off and On

I would like a doctor who accepts my insurance benefits:
	Insurance Company Type of Plan HMO PPO POS EPO No Insurance (payment plan) Workers Comp Medicare
I would like a doctor's office location:
	Close to home Close to work place Both
	Work Zip (if applicable):
Desired Time For Appointment:
	Day of Week: Hour of Day:
	This week Next Week
Any Specific Comments, Concerns or Questions:

Please make sure you entered your phone and e-mail information, then click submit. We will contact you shortly to confirm your appointment.