Where Do you feel Pain? *

Low back

Upper back

Neck

Legs or arms

Do you experience pain in the legs?

Yes

No

Do you have tingling and numbness in the legs or arms?

Yes

No

What treatments have you tried?

Chiropractic adjustments

Massage Therapy

Acupunture

Medications/Injections

Physical Therapy

Surgery

None

Would you like us to contact you directly to discuss options?

Yes

No

Name *

First Name

Last Name

Phone *

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