Register below for the opportunity to come in for an Introductory Chiropractic Assessment of your spine and posture, computerized muscle tension scan, followed by a review of findings on your next visit, and a GIFT CARD loaded with FREE 30-min Massage!
Your Name
*
First Name
Last Name
City
*
City
Telephone
*
xxx-xxx-xxxx
E-mail
*
Age
*
Check all of the symptoms you have experienced in the past 6 months:
Headaches
Neck Pain
Back Pain
Leg or Hip Pain
Arthritis
Shoulder/Arm Pain
Carpal Tunnel Pain
Irritability
Dizziness
Problems Sleeping
Weight Trouble
Low Energy/Fatigue
Tingling/Numbness in Arms or Legs
Other
Which of the above symptoms concerns you the most?
Concerning that symptom, how long have you experienced it?
Are any of the above selected symptoms the result of a recent auto accident?
*
Yes
No
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Complimentary package is valid for local residents only (living or working in the Queens NY area).
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One complimentary package per person. Not available for individuals on federal programs such
as Medicare or Medicaid.
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