Your name:


Your email address:


Date you were injured or first learned of your injury:


Give us a very brief description of how your injury occurred (car accident, injured on board a vessel, medical malpractice, etc.) including the name(s) of the person or person you believe caused your injury:

Describe your injuries:

What have been your approximate total medical expenses due to this injury including any amounts paid by any insurance company:

If you’ve lost time from work, please tell us how many days or weeks:

Was this injury suffered on the job?
No Yes

Are more than 50% of your medical expenses due to chiropractic care?
More than 50% Less than 50%

We will try to respond to all inquiries for consultation with 3 working days. If you don’t hear from us within that period of time, please call our toll-free number 1-888-659-2525.