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.
Name Age Street City State Zip Phone Work Male Female Occupation Email URL
Please mark any of the following that apply to you.
Is your condition related to an automobile accident? Is your condition related to an accident that occurred at work? Has the 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 condition here.
If your answer is Yes, there are a couple alternatives available to you.
I would 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 barriers.
I 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 DrTom@Vitalityweb.com or call (619)296-BACK(2225) for additional information.