Salama Chiropractic Center - Appointment Request

Appointment Request

If you would like to request an appointment, please fill out all fields in the form below.

Name:

Address:

City:

State:

Zip:

Phone/Cellphone:

E-Mail Address:

What are your symptoms?

(Ex: Auto accident, low back pain, neck pain, headaches):

Filing health insurance? (Yes or No):

Appointment date:

Appointment time:

Which office?

(Wendover Avenue, Lawndale Drive, Oak Ridge, Winston-Salem):

Greensboro-Lawndale Dr. Office		Oak Ridge, NC Office		Winston Salem, NC Office
2608-A Lawndale Dr. Greensboro, North Carolina 27407 Phone: 336-540-1040 Fax: 336-540-1041		1692 NC Highway. 68 Ste. E Oak Ridge, North Carolina 27310 Phone: 336-644-6446 Fax: 336-644-6442		1515 Hanes Mall Blvd. Winston-Salem, North Carolina 27103 Phone: 336-773-7373 Fax: 336-765-7006