First Name *

Last Name *

Email *

Phone *

What is the age of your oldest living parent or grandparent, or what was their age at the time of their passing? *

Do you have an active diagnosis? *

Yes

No

What condition(s) are you experiencing? *

What have you tried in order to solve this pain or dysfunction? *

Check all that apply to you. *

Have had to get a cortisone injection.

Have been told I need surgery.

Neck pain or back pain.

Sciatic/Radiating Pain into arms/hand or Legs/Feet

Knee, Hip or Shoulder Pain

Degenerated or Bulging/Herniated/Protruding/Extruded Disc

Spinal Stenosis

Bone on Bone or Tears in Your Joints

Neuropathy Numbing/Tingling/Burning in Hands/Feet

What is your level of urgency to solve this problem? *

1-6 (not urgent)

7-10 (very urgent)

What are you trying to achieve by asking us for help? *

If we are confident that we can help you to solve your problem and accept you as a patient... *

I have access to the resources to invest in my health

I do not have the resources to invest in my health