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Contact Us to Join in our Mission of Uncovering the Truth about Strokes Induced by Chiropractic

Chiropractic Stroke Awareness Organization is a non-profit entity dedicated to understanding, evaluating and researching the risks of stroke induced by chiropractic upper cervical manipulation, as well as providing support for stroke victims and their families.

Call us at 866.409.5413 or complete the form below to express your interest in joining us in our quest to raise awareness and increase knowledge about this issue.

Inquiries from stroke victims, families of stroke victims, chiropractors, medical doctors, other health professionals, researchers and concerned citizens are welcome. Help our North American non-profit organization move forward for the sake of helping prevent future strokes caused by upper cervical manipulation.

P.O. Box 197
Mahopac Falls, NY 10542
866.409.5413 (phone)
845-566-7288 (FAX)

NOTE: An asterisk (*) indicates REQUIRED information. The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

Stroke Victims and Their Families

*Name:
Street Address:
City:
State:
Zip:
Phone:
Fax:
*E-mail Address:
Date of injury:
Date of chiropractic treatment:


Please provide a brief account of what happened and your current condition:


How would you like to be contacted?
E-mail Phone	Fax Postal Mail

Are you seeking support and information: Yes No

If yes when is the best time to contact you:

Are you willing to provide your primary medical and chiropractic data for a retrospective study on chiropractic stroke occurrence? (anonymously if preferred): Yes No

Do you want to share your story on the website?: Yes No

Would you like to share our story via the media (e.g, television shows, magazine articles, other printed forums, news shows, etc.): Yes No

Other interested parties

Name:
Street Address:
City:
State:
Zip:
Phone:
Fax:
E-mail Address:

Would you like to join our mailing list to receive updates on our progress?: Yes No
Would you like to become more involved with our organization?: Yes No
If yes what capacity? and when is the best time to contact you?:

Chiropractic Stroke Awareness Organization is both national and international in scope, headquartered in Newburgh, New York, and reaching out to stroke victims and others throughout North America who share an interest in our mission.

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