OPT-IN TEMPLATE - Bodywork Sampler Package Form

Register below for the opportunity to come in for a discounted Bodywork Sampler Package!
The Bodywork Sampler Package includes: initial exam by the doctor and your first adjustment. During your initial exam the doctor will go over your Medical History with you, followed by a Range of Motion Examination, if the doctor feels that X-Rays are needed they will NOT be covered under this package.
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?
Which of the above symptoms concerns you the most?
Are any of the above selected symptoms the result of a recent auto accident? *

Yes No
■ One package per person.

■ This offer only valid for first time clients.

■ This package does NOT include X-rays.
Should be Empty: