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Back and Joint Pain Institute

1720 South 72nd St., Ste 201

Tacoma, WA 98408

253-498-6937

Personal Information

First Name *

Last Name *

Gender

Male

Female

Date of birth *

Email *

Phone *

What is your preferred method of communication?

Text

Phone call

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?

Are you currently employed?

Yes

Are you retired?

Yes

What is your marital status?

Single

Married

Widow

Most of our patients want more advanced, drug-free therapies that go beyond the basic coverage of most insurance plans. Are you willing to invest in your health if you felt the doctor's recommendations could help you achieve your health goals?

Yes

Any other comments?