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.
General / Family Doctor
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)
Please choose an insurance plan*
BlueCross / BlueShield
Cash / Out of pocket
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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
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