Online Health Form

Online Health Form 2017-09-08T21:44:08+00:00

Fill out the Online Health Form and get $20 off applicable on your initial examination.

Like us on Facebook and double your rebate, $40 off for your first exam.

Name *

Address

Email

Phone *

1. Do you recognize these symptoms?

Low back painNeck painPain between the shoulder bladesTension / headacheShoulder tensionFatigue / ExhaustionDizzinessWhistling in the earsNumbness / tingling in arms or handsNumbness / tingling in legs or feetNervousness, sleep disordersDigestive problems

2. Which of these symptoms affects you the most?

3. Since when do you feel it?

months

If you recognize these symptoms, you may be suffering from vertebral subluxation.

We can help you

Doctors in chiropractic treat the body naturally without medication by eliminating the vertebral subluxations that cause health problems.

Would you like to improve your health?

YesNo

If you answered yes, several alternatives are offered. Check the one that best suits your needs:

I'd like to meet the doctor for an evaluation (by completing this form, you will get $20 off an initial consultation)I'd like to talk to the doctor by phone about my health problems before making an appointment

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