Appointment Request

If you would like to request an appointment fill out 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 or Lawndale)

Privacy Statement:
The information which you give in completing this form will be forwarded to Salama Chiropractic staff and will not be used for any other purpose.

©2006 Salama Chiropractic
3410 W. Wendover Ave. Ste. A Greensboro, North Carolina 27407
Phone: 336-274-3500 / Fax: 336-292-1928