Step 2: Fill Out The 1-Minute Pain Assessment Form Below

This will give our team a great introduction to your situation, so that we know how to best help you!

Please Note: Expect a call from our team. We are only offering a LIMITED number of vouchers for this deeply discounted special. If you are experiencing back pain, neck pain, herniated disc, radiating pain in the arms and legs, then let's get you OUT OF PAIN and into relief today!

Please Complete Our Pain Assessment Below 👇

Select all that you are experiencing: *

Back Pain

Neck Pain

Arm Pain

Leg Pain

Sciatica

Muscle Stiffness

What symptoms are you experiencing?

Stiffness/Tightness

Numbness/Tingling

Sharp Shooting Pain

Muscle Weakness

Headaches

None Of These

Describe if/how this is affecting your life in any way. *

How long has this been an issue for you? *

1-6 months

6-12 months

1-3 years

3+ years

Have you ever had surgery for this issue? *

Yes

Select what currently applies to you: *

I'd like to get relief as well as have a better understanding of the root cause of my problem.

Relief is not that important to me right now - I just want to have a better understanding of my problem.

If a solution to your problem is possible, are you prepared to invest time, money, energy to work on it? *

Yes

Not Sure Yet

What is the name of your insurance carrier? *

Are You On Medicaid, Disability, Or State Assistance? *

Medicaid

Disability

State Assistance

All of the above

None of the above

What type of insurance coverage do you have? *

PPO

HMO

Cash Patient

Not Sure

Full Name *

Phone Number *

Best Email Address *

Step 2: Fill Out The 1-Minute Pain Assessment Form Below

This will give our team a great introduction to your situation, so that we know how to best help you!

Please Complete Our Pain Assessment Below 👇

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Address: 300 Broadacres Dr Suite 126, Bloomfield, NJ 07003