If you are interested in joining Accident Chiropractors, please fill out the form below:.
If you have any questions, please call Dennis Goldberg, DC at (Cell): 602-989-6789.
E-mail to: drgoldberg@accidentchiropractors.com
or
Fax to: (602) 252-0845
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Dr. Name: ____________________________________________
Clinic Name: __________________________________________
Address: _____________________________________________
City: ____________________ State: ____ Zip Code: __________
Cross Streets: _________________________________________
Landmarks/Sign: _______________________________________
Office Telephone No: ____________________________________
Office Fax No: __________________________________________
Dr. Cell No: _____________________________________________
Office Hours: ____________________________________________
E-Mail: _________________________________________________
Spanish Speaking: YES NO Other: _________________
Available on Weekends/After Hours? YES NO
ADDITIONAL iNFORMATION: ______________________________________________________________
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