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Eligibility Assessment
Name
Email
Phone
How long have you been experiencing pain?
Please select all primary pain areas you are experiencing:
Neck
Midback
Low Back
How would you describe your pain?
Dull
Sharp
Shooting
Burning
Numbness/Tingling
How often do you experience pain?
Which healthcare providers have you consulted previously regarding your condition?
Medical Doctor
Physical Therapist
Chiropractor
Other
Do you have an MRI of Neck or Low Back?
Are there any questions you need answered by the doctor?
Submit
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