Alliance Chiropractic Center Dr. Fred M. Bogan
Name Age Phone (Home) ( Work ) Address City
State Zip
Occupation # Hours per week currently working
Spouse Occupation # Hours per week currently working
Your E-Mail Address
Check off any of the following symptoms you have experienced in the past 6 months:
Which of the above bothers you the most?
How long have you been bothered by this condition?
Describe how it feels or affects you when it is at its worst.
Does this cause you to be: Does this affect your work ? Does this affect your Life:
If you checked any of the above items, then you could be suffering from . . .
Alliance Chiropractic Can Help You because Dr. Fred Bogan gently treats the body, naturally, without drugs to remove the stress and imbalances that CAUSE health problems.
If you could eliminate one of the above which would it be?
There are several alternatives available to you. Please check the item most appropriate for you. I would like to come to Alliance Chiropractic Center for a complete evaluation.
I would like Dr. Fred Bogan to call me to discuss my health problems before making an appointment.
Are you a member of an HMO or Health Care Network? YES NO
Health Care Provider