Please rate your pain from 1 - 10.
(1 = no pain), (10 = excruciating pain)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Where is the source of your pain? Choose all options that apply.
Neck
Back
Knee
Shoulder
Arms
Legs
Headache
Other
What type of doctors have you seen? Choose all that apply.
Chiropractor
Pain Management
Neurologist
Orthopedic Surgeon
General / Family Doctor
Other
None
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)
Please choose an insurance plan*
BlueCross / BlueShield
Cigna
Aetna
PHCS
Guardian
Cash / Out of pocket
Other
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How commited are you to fixing your pain?
Please choose your commitment level
Very committed
Somewhat committed
Not ready to committ
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PLEASE ACKNOWLEDGE YOUR APPOINTMENT:
I will NOT miss my appointment once it is scheduled. I will respect your time and understand it's not fair to others who would schedule in my place if i don't show up.
Yes
No
CONGRATULATIONS, you qualify for our chiropractic care.
Please fill out the form below to complete and then schedule your appointment.
Your voucher will be sent to your email address. Please check your spam folder if you haven't received it within 5 min.