When you're done, simply indicate whether you'd like us to contact you by phone or e-mail to discuss your health plan options as well as explore the possibility of scheduling you for a consultation and examination.

Health Insurance Coverage Questions?
We will gladly contact your health insurance company to determine the extent of chiropractic health coverage you have with our office. Simply include the information in the appropriate form fields below. (note: there are no out of pocket expense for most work-related and automobile accident injuries.)

Your Confidentiality Is Important To Us
Any and all information submitted is and will remain confidential.

Check any of the following symptoms that apply to you: Back or Neck Pain, Stiffness, Soreness Headaches Pain between the Shoulder Blades Muscular Spasm and Tightness Pain, Numbness or Tingling in Extremities Chronic Pain Painful Joints Excess Stress Dizziness or Loss of Balance Low Energy and Sluggishness Over the last 12 months have you been involved in: select all that apply Auto Injuries Work Injuries Sports Injuries Other Injury If "Other Injury", please explain: How has your health condition impacted your life? i.e. prevented you from doing? What health goals have you set for yourself recently or would you now like to set? check all that apply To initiate or improve upon a fitness/exercise program To lose excess body fat To build extra muscle To consume a healthier, more nutritious diet To participate in a preventative health plan to increase overall health and well-being Other:   Place questions and concerns you would like to ask the doctor here. Complete the area below if you would like us to check your insurance coverage: Health Insurance Company: Subscriber ID: Group or Plan Number: Phone Number: If the information on your health card does not match the above or there is additional information, please include it below: Give us some information about yourself. *  Name: *  Street Adress: *  City: *  State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming      Zip: *  Email: *  Telephone: *  Age: *Male Female *  How Should We Contact You? *   Home Telephone Work Telephone E-Mail *  Required Information