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(203) 316-8477

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Reactivation Update

Home   Reactivation Update

Welcome Back!

Advanced Chiropractic & Wellness Re-activation Form

Do you have new insurance?*
Please select at least one option
If yes, please bring your new insurance card to your appointment.
3. Is it accident related?
5. Have you had this problem before?
6. Do you have pain or tightness?
8. The pain is (check all that apply):
9. I have (check all that apply)
Please mark all areas of pain on diagram below (A=aching B=Burning N=numbness P=pins and needles S=Stabbing pain O=other type of sensation)

Thank you for taking the time to fill out this form.
Contact
us
Office hours 
& location
Monday
12:30 PM — 8:00 PM
Tuesday
9:30 AM — 6:00 PM
Wednesday
7:30 AM — 1:00 PM
Thursday
9:30 AM - 8:00 PM
Friday
8:30 AM - 4:00 PM
Saturday
8:00 AM - 2:00 PM
Sunday
Closed
Our location
1150 Summer St
Stamford, CT 06905

(203) 316-8477
We help individuals overcome pain and regain their mobility, providing personalized care solutions to help you get back to doing what you love quickly and effectively.
EXPLORE
OUR LOCATION
1150 Summer St
Stamford, CT 06905