Free Consultation Form
You will be contacted by Dr Lanzarotta’s office
to schedule your initial phone consult.
First
Name

Last Name
Address
City
State
Zip
Country

Email
Fax
Primary Phone

Secondary Phone

Preferred method of contact:
When is the best time to reach
you?
Flexible Date Available for Consultation:



List the urgency of your inquiry
(1-10)
 
1= Immediate Call Back 3=Important
How old (young) are you?

(You must be older then 13)
Date Preferred for Consultation:
What is your health priority?


Specific Treatment or Service
of Interest:
Other Treatment or Service of
Interest:
Please
select all that apply
Health
Goals
I need to get in shape
Detoxify and Cleansing
Chiropractic Treatment
Multiple Approach: Homeopathic & Mainstream
Natural Treatment of Health Conditions
Health
Conditions
Pain: Back, Neck, Arthritis etc
Chronic Illness: Cancer etc
Weight Struggle: Over/Under
Allergic: Please list known allergies below

In general, would you say your health is:



Excellent

Very good

Good

Fair

Poor

Please
give us more information about you and any conditions:

I have Read and Accept the Terms
of Use


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    information on this site for diagnosis or treatment of any health problem
    or for prescription of any medication or other treatment. You should
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