First Name

Last Name

Email *

Phone *

Please select a condition that relates to your condition. *

How long have you had this problem? *

Is it staying the same or getting worse? *

On a pain scale from 1-10 (10 being the worst), how would you rate your pain? *

I have seen a Doctor for this condition

I have had cortisone shots for this

If yes, When?

What is the name of your spouse or loved one involved with your care?

Do you have insurance?*

Innovative Medical Center is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you: