Where is the source of your pain? (Click Next Below 👇 to Select)
Choose all options that apply.
Headaches
Neck Pain
Shoulder Pain
Mid-Back Pain
Elbow Pain
Lower Back Pain
Hip Pain
Wrist Pain
Knee Pain
Foot and Ankle Pain
Heel Pain
Other
Please rate your pain from 1 - 5.
(1 = no pain), (5 = excruciating pain)
1
2
3
4
5
What type of doctors have you seen? Choose all that apply.
Chiropractor
Medical Doctor
Physical Therapist
Other
Have you had any surgeries to your existing pain or condition?
Yes
No
Which insurance (if any) do you have? (We are NOT a Medicaid provider)
BlueCross / BlueShield
Cigna
Aetna
United Healthcare
Cash / Out of Pocket
Other
Are you interested in a quick fix or a long lasting solution?
Quick Fix
Long Lasting Solution
CONGRATULATIONS, you qualify for our chiropractic care.
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