Where is your pain located? * *

Hips / pelvis

Sciatica / leg pain / arm pain

Neck

Other

How would you rate your pain or discomfort today? (On a scale of 1–5) *

1 – Mild

2 – Moderate

3 – Uncomfortable

4 – Severe

5 – Very severe

Please describe the issue or pain you're experiencing. *

How long have you been dealing with this issue?

Less than 6 months

6-12 months

Over 3 years

Do you feel the pain spreading into your arms or legs? *

Yes

No

What symptoms are you currently experiencing? (Select all that apply) *

Pain when moving, walking, bending, or lifting

Swelling or stiffness

Numbness or tingling

Joint instability or weakness

Shooting pain (e.g. down the leg)

Clicking, popping, or joint locking

Difficulty standing, sitting, or climbing stairs

None of these

Have you had any spinal surgery before? *

Yes

No

Do you have any metal implants, hardware, or a pacemaker? *

Yes

No

Have you been diagnosed with any of the following? (Select all that apply) *

Bulging / herniated disc

Degenerative disc disease

Spinal stenosis

Sciatica

None of the above

Are you actively looking for treatment or just exploring? *

Actively looking

Just exploring

Not sure

What's your credit score range? *

580

580-650

Below 580

If you qualify, are you ready to start treatment? *

Yes, I’m ready to get started

Not yet, just researching

What's your age? *

Address

Street Address

City

State

Country

Country

Postal code

Full Name

Phone *

Email *