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Experience and respect for your patients…and for your practice
   
 
 
Chiropractic Presentation - Contact Form
*Dr.’s Name requesting presentation:
*Address of Office:
Location of presentation (if other than office location) :
*Office telephone #:
Cell Phone:
*Your E-Mail Address:

*Presentation(s) that you are interested in:

For mulitple selections:
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Will you be actively promoting the presentations requested within your practice and throughout the community?:

Yes
No

When would you like to schedule your office/community workshop?:
Comment: