Consultation

If you are living far we recommend you to answer the questionnaire below and attach your X-ray, CT-scan or MRI reports. Our doctors will be glad to review it and contact you about your condition. Thank you.

* indicates required field

Email:*

Subject:*

Message:

First Name:*

Last Name:*

Your Age

Your Gender*

male female

Where do you have pain (neck, back, leg, list the worst pain area first)

Do you have any tingling or numbness? Where?

Are you able to walk without difficulty?

Yes No

How long you had this pain?

On the scale of 1 to 10 give a number that describes the level of your pain (10 is the worst pain you ever felt)

What kind of work you do?

Hard Labor Clerical

Have you had any traumas? (Car accident? Fractures?)

Yes No

Have you seen any doctor for this problem and do you know your diagnosis?

What makes your pain worst? (Sitting? walking? movement)

What makes your pain better? (Resting in bed)

Do you have any other serious medical conditions? (Tumor, heart disease, neurological disease)

What kind of treatments have you received?

Did the treatments help?

Yes No

Have you been recommended to undergo a surgery?

Yes No

Your Email (required)*

Your telephone number

Please attach your diagnostic files

Acceptable file types: doc,docx,pdf,txt,gif,jpg,jpeg,png.
Maximum file size: 1mb.

Search for:

Contact Form

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Submit your contact information to see if you qualify for our treatment programs.

Name *

Email *

Phone *

Office Hours

Day	Morning	Afternoon
Monday	9:30am	7:00pm
Tuesday	9:30am	7:00pm
Wednesday	9:30am	7:00pm
Thursday	9:30am	7:00pm
Friday	9:30am	7:00pm
Saturday	10:00am	4:00pm
Sunday	Closed	Closed

Consultation Form

Consultation