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Name

First Name

Last Name

Phone

(###)

###

####

Briefly describe what your current challenges are.

On a scale of 1 - 10, 10 being awful, how would you rate your pain today?

Why do you believe this treatment will help you?

If you are under the care of a physician, please enter their name and telephone number here.

Have you discussed this treatment with him/her?

Thank you!

Life Readiness Center at Joint & Spine Center

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