Fill Out The Quick Survey Below To Secure Your Spot

So we'll know how to help

Please Note: If you do not fill out the evaluation, we will not be able to secure your spot with this special offer for a Rapid Back Pain Relief Program Consultation + Exam, & New Patient Special

What back pain symptoms are you experiencing?

Sharp pain in the back

Back muscle spasms

Trouble standing or sitting

Pain when walking short distances

On a scale from 1-5, 5 being excruciating, how bad is the pain in your back?

1

2

3

4

5

How long have these symptoms been bothering you?

Less than 1 year

1-3 years

4-6 years

6+ years

Have you been diagnosed with any of the following conditions?

Herniated disk

Sciatica

Generative disc disease

Stenosis

None

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