Referral Form

pay it forward


Do you know someone who could benefit from chiropractic care?  If so, fill out the form below so we can let them know how we could help them achieve their health goals.

As a bonus, you’ll be entered to win an ebook copy of Simple Reminders: Inspiration for Living Your Best Life as well as a FREE new patient voucher to give to a family member, friend or co-worker.

What are some common reasons people seek chiropractic care at Healing Hands Community Chiropractic?

  • Allergies
  • Arthritis
  • Asthma
  • Back Pain
  • Breech Baby
  • Colic
  • Dizziness
  • Ear Infections
  • Frequent Cold/ Flu
  • Headaches
  • Healthy Pregnancy
  • Heartburn
  • Hip Pain/ Leg Pain
  • Infertility
  • Irritable Bowel Syndrome (IBS)
  • Latching issues
  • Menstrual/ Menopausal Problems
  • Numbness and Tingling
  • Poor Posture
  • Reflux
  • Sciatica
  • Scoliosis
  • Sinus Problems
  • Stress Relief
  • TMJ Problems
  • Torticollis

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    Referral Name

    Referral Email Address

    Referral Phone Number


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