If you are interested in a personal contact from a Doctor of Chiropractic
or in receiving new patient information, please complete the form below. To
assist the doctor we kindly ask that you be as thorough as possible. For a
free consultation, please call DR. TOM at: (619) 298-BACK (2225). Thank you.
City State Zip
Phone Work Male Female
Please mark any of the following that apply to you.
your condition related to an automobile accident?
condition related to an accident that occurred at work?
pain changed your quality of life?
Headaches Neck Pain Low Back Pain Joint Pain
Fatigue Nervousness Dizziness Pain Between Shoulder Blades
Weakness Numbness Tingling Tension Across Top of Shoulders
Irritability Trouble Sleeping Allergies Digestive Problems
Which of the above bothers you the most?
How long have you been bothered by this condition?
Please include any additional comments or information regarding your
If your answer is Yes, there are a couple alternatives available
like to come to the Doctor's office for a complete evaluation. There
is NO CHARGE for this examination. This will allow me to find
out if I can be helped by Chiropractic without any financial
would like the Doctor to call me to discuss my health problems before
making an appointment.
If the form does not work for you you may send the information
via e-mail to Dr. Tom at
or call (619)296-BACK(2225) for additional information.