Back to Health

"Free Massage" Entry Form

*Required Information*
First Name
Last Name
Address
City
State
Zip Code
Telephone (Day)
Telephone (Evening)
eMail

Optional Information

Occupation

Weekly Hours

Spouses Occupation

Weekly Hours

Check any of the following symptoms you have experienced in the past 6 months

Low Back Pain	Neck Pain or Stiffness	Low Energy
Mid Back Pain	Headaches or Migraines	PMS
Shoulder Pain	Carpel Tunnel	Digestive Trouble
Arm or Leg Pain	Arthritis	Allergies
Disc Problems	Unresolved pain despite medical treatment

Which Problem is the Worst?

How Long Have You Had It?

Any Accidents? Work Date | Auto Date | Other Date

Would you consider chiropractic treatment?

Would you like to come to a doctor's office for a complimentary exam?

Check here if you DO NOT wish to receive further information from Back to Health

"Must be 18 years or older. Prizes are redeemed at the above location.
Consultation with doctor or meeting with his assistant is required
(Complimentary!)"

For entry rules please click here: Official Rules