ADVANTAGE

CHIROPRACTIC

Dr. Joseph A. LaScala - Treating Physician/Owner

Advantage Chiropractic
7400 Lewis Ave., Suite J
Temperance, MI 48182
United States
ph: 734-847-7640
fax: 734-847-7486

Patient Information Sheet

To become a patient/client for our office, please fill out the form below and someone will contact you within 24 hours. We have also provided an option for you to print and fill out our patient information sheet to help minimize the paperwork process when you come in for your first appointment. Patients that have had their visits extended out to a "as needed basis" may also use this form to update their records if needed. Click here to print the patient information sheet. Please bring form with you to your visit.

Please note that any information obtained below will only be used for our office. We will not give out any information to a third party. All information here comes directly to our office and will not be handled by anyone other that the staff members at Advantage Chiropractic. Please contact us at 734-847-7640 if you have any questions or concerns. Thank you.

*First Name:

*Last Name:

*Date of Birth:

Email:

*Phone:

*Address:

*City:

*State/Province:

*ZIP/Postal Code:

*Contact Preference:

Service Requested:

Please list why you are visiting our office. Chiropractic Services or Massage Therapy

Comments:

Please list any problems or concerns that you would like our doctors or therapists to know about.

Submit Your Message:

Thank you and we look forward to speaking with you soon!

All information contained on the Advantage Chiropractic website is intended for informational and educational purposes. The information is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition.

We urge you to always seek the advice of your physician or medical professional with respect to your medical condition or questions. As a recipient of information from this website, you are not establishing a doctor/patient relationship with any physician. There is no replacement for personal medical treatment and advice from your personal physician. We encourage you to speak with our doctors for advice! Call us today!

Advantage Chiropractic
7400 Lewis Ave., Suite J
Temperance, MI 48182
United States
ph: 734-847-7640
fax: 734-847-7486

ADVANTAGE

CHIROPRACTIC

Dr. Joseph A. LaScala - Treating Physician/Owner

Patient Information Sheet

We're so happy you've made the decision to obtain optimal health with our office!