International Headache Center

10 Medical Parkway, Suite 203 - Plaza 3
Dallas, Texas 75234

Ph: 972-685-7175
Fax: 972-685-7239

Email Us
Sign Up

Name *

Name

First Name

Last Name

Email Address *

Message *

Phone

(###)

###

####

Who referred you to us?

Become a International Headache Center Insider!

Yes, I'd like to be notified of updates and special offers.

This is a non-secure communication. You must indicate your acceptance to the use of this form by checking the box below *

I hereby acknowledge that this form is unencrypted and not a secure means of electronic communication with my healthcare provider or facility. I agree to allow my healthcare provider or facility staff to reply to the email address indicated on this form, and to forward or share the information contained in this form, including any Personal Health Information (PHI), with other health professionals or associated staff using non-secure electronic communication methods such as email.