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We know the internet can be a bit scary but our patient database is secure and 100% HIPAA compliant so we want you to know that your information is private and totally secure.

Back and Joint Pain Institute

1720 South 72nd St., Ste 201

Tacoma, WA 98408

253-475-0780

https://backandjointpaininstitute.com

Personal Information

First Name *

Last Name *

Gender

Male

Female

Date of birth *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Have you been in a car accident in the past 3 years?

Yes

Date of the car accident?

Do you have any X-Rays?

Yes

Have you had an MRI done?

Yes

What insurance(s) do you currently have?