Please rate your pain from 1 - 10.
(1 = no pain), (10 = excruciating pain)
Where is the source of your pain? Choose all options that apply.
What type of doctors have you seen? Choose all that apply.
Have you had any surgeries to your existing pain or any other pain condition?
Which insurance (if any) do you have? (We are NOT a Medicaid provider)
How commited are you to fixing your pain?
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.
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.