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Patient Name (required) :

Date :

Home Phone :

Cell Phone :

Complaints:
Mechanical back painThoracic Outlet SynSprain/strain injuryFibromyaigiaMyofascial painCarpal Tunnel SynFacet Joint DysfunctionExtremity PainSI Joint DysfunctionSports InjuryDisc lnjury / Bulge / HNPWork InjurySciatic or NeuritisAuto InjuryNeck Pain/ WhiplashChronic Pain SyndromeThoracic Pain
Other Complaints :

Please provide the following service(s):
Evaluate and treat as clinically appropriateTreat for 4 weeks and return to this office for a follow upNutritional Consulting (anti-inflammatory diet)Self-Care StrategiesEducation on avoiding aggravating factorsWork Smarter TrainingOther Instructions

Referred By:

Referred By Phone No :

Number to Fax a Clinical Report :

PLEASE FAX TO (404)320-6073

Appointment Number 404-333-7777