Jared Simon Atlanta Chiropractors chiropractor

Atlanta Chiropractor

Welcome New Patients

Special Gift
Fill out this form and your exam fee which includes orthopedic, neurological, spinal tests
and if necessary, two x-rays,.........will be waved.
$175 VALUE
Any further treatment shall be agreed upon in writing and signed by both parties.

Reason for Your Visit
We will confirm your appointment by phone within 48 hours

Name

Age

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Work Phone

Home Phone

FAX

E-mail

Occupation
Have you ever been treated by a Chiropractor before?
yes no
If so, please explain:
The reason for this visit is a result of:
work related accident sports injury auto accident trauma
chronic pain normal daily activity
Explain the pain/problem your having and it's location:
When did condition begin?
Is this condition getting worse?
yes no constant comes and goes
Is this condition interfering with your work, sleep, or daily routine? If so, please explain:
Have you had this or similar conditions in the past?
yes
no
If so, please explain:
Have you been treated by a Medical Physician for this condition?
yes
no
If so, where?
You must check here if you're using a Special Gift Certificate
YES

**404.634.1669** *FAX: 404.634.1442*
Office Directions, Hours	FREE First Exam	Insurance Information
Headaches	New Patient Appointment Form	SCIATICA
Low Back Pain	Email Dr. Simon	SCOLIOSIS
Neck Problems	Home	STRESS
Stress Survey	Patient Testimonials	Corporate Workshops
Atlanta Plastic Surgeons	www.calladoctor.net

immediate care clinics atlanta georgia	buckhead urgent care centers	emergency care clinic atlanta	piedmont minor emergency clinic
physicians immediate medical care atlanta		Atlanta Plastic Surgeons

Atlanta chiropractor chiropractors Chiropractor
Dr. Simon is nationally and state Board Certified and has been practicing in Atlanta since 1992. He is extensively trained in many techniques such as Gonstead, Motion Palpation, Thompson, Pierce, Activator, HIO, and S.O.T. Dr. Simon uses state of the art diagnostic and therapeutic equipment and we have a massage therapist on staff Atlanta Chiropractor chiropractic
calladoctor.net

Name
Age
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail
Occupation