Houston Chiropractor Appointment Scheduling

*Patient Name:

*Date of Birth (MM,DD,YYYY):

Address line 1:

Address line 2:

City

*Area Code, *Phone#, & Ext:

*Area Code, *2nd Phone#, & Ext:

*Email Address:

Do you have insurance?
Yes No

Insurance Company:

SS# or ID#

Group# or Claim#

Insurance Company Phone:

Please indicate area or complaint:
Headaches?
Tingling in the arm & hand or legs?
Wrist Pain?
Low back pain?
Neck Pain
Muscle spasms?
Sports related injury?
Other?

If Other checked, please explain:



Have you been to a Chiropractor?
Yes No

Have you had X-Rays?
Yes No

CHIROPRACTIC APPOINTMENT I would like to Set Up a Chiropractic appointment:
Pease refer to office hours above.
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Date:

THERAPEUTIC MASSAGE
I would like to Set Up a massage appointment:
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Date:

15 min. massage @ $20.00
30 min. massage @ $35.00
45 min. massage @ $50.00
1 hour massage @ $65.00 

*Receive a complimentary office visit for
every new patient referred by you!