First Name *

Last Name *

Phone Number *

Email Address *

Requested Therapist * Requested Therapist *Dr. Roger Karam, Chiropractor

Preferred Location * Preferred Location *OshawaPort Hope

How Did You Hear About Us? * How Did You Hear About Us? *DoctorSocial Media (Facebook, Instagram)NewspaperGoogleLocal EventsFamily or Friend Referrals (Please Specify below)I am an Existing Patient

Preferred Date

Preferred Time(s)

Additional Comments