1.) Do you have a herniated or bulging disc? *

Yes

I'm not sure

2.) What is your age? *

60+

50-59

40-49

<40

3.) Do you have an MRI of your spine (lumbar, cervical, thoracic)? *

Yes

4.) How long have you been dealing with your pain? *

6 months

1-4 years

5-10 years

10+ years

5.) Are you currently unable to walk and function as you wish (or have to modify the way you function)? *

Yes

6.) Have you received any of the following? Check all that you've had. *

Pain medication prescribed

Epidural/Cortisone shot

Physical Therapy

Traditional Chiropractic

None of the above

7.) Have you gotten any of these surgeries done yet? *

Discectomy or microdiscectomy

Laminectomy

Spinal Fusion

None of the above

8.) Are you currently using any of the following? *

Cane

Walker

Wheelchair

None of the above

9.) How ready do you feel to do something about your situation? *

Somewhat ready

Very ready

I need something fast!

10.) Non-surgical, non-invasive spinal decompression treatments are not fully covered by insurance. However, many affordable payment plans are available. Are you interested in a payment plan option? *

Yes. I'm interested in affordable payment plan options.

No. I've been saving for this type of treatment and will not need a payment plan.

11.) Payment Plan Options are available based on credit approval of the patient or a co-signer. Which best describes your credit? *

(Excellent) 750+

(Good) 650-749

(Poor) 500-649

(Very poor) Under 500

Full Name *

Email *

Phone *

Location *

Van Nuys
Culver City
Ontario
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