Please provide the following CONTACT information:

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail
URL

Please identify and describe YOURSELF:

Date of Birth
Sex	Male Female
Height
Weight

Please describe your CONDITION, injury or problem:

How do you intend to PAY for your services?

          Cash/Check/CreditCard Insurance    If by Insurance, complete the following...

Insurance Type	-------Choose One--------- PPO Medicare POS Workers Comp Auto Insurance - Medpay I have an Attorney Do Not Know
Insurance Co. Name
Insurance Co. Ph#
ID#
Group # (if applicable)

Who is REFERRING you?

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
FAX
E-mail

We don't accept all insurances.  We do not accept HMO's.

A representative will make contact with you by phone or email to
notify you of your acceptance or denial.  We sincerely apologize
that we are unable to accept everyone into this program.