Identify your pains! (Click ▶ Below 👇 to Select)

Choose all options that apply.

Headaches

Neck Pain

Shoulder Pain

Mid -Back Pain

Elbow Pain

Lower Back Pain

Hip Pain

Wrist Pain

Knee

Foot and Ankle Pain

Heel Pain

Other

Please rate your pain from 1 - 5.

(1 = no pain), (5 = excruciating pain)

1.

2.

3.

4.

5.

Have you had any surgeries to your existing pain or any other pain condition?

Yes

No

Which insurance (if any) do you have?

(WE ARE NOT A MEDICAID PROVIDER)

CONGRATULATIONS, you qualify for our Chiropractic Care.

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⚠ (PLEASE NOTE . . . IF YOU DON'T CLICK THE ORANGE SUBMIT AFTERWARDS, YOUR APPOINTMENT WILL BE CANCELLED) ⚠

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