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NEW PATIENT FORM
Take our 2 minute survey to see if you qualify for our $49 Neuropathy consultation package.
What is the problem you are experiencing? (Choose as many as you like.)
Small fiber neuropathy
What is your pain / discomfort level on a scale of 0-10?
Describe your pain/ discomfort. (Choose as many as you like.)
Numbness & Tingling
How long have you had this problem?
0 - 3 months
3 - 12 months
1 - 3 years
Over 3 years
How many doctors have you seen for this problem?
What have you tried in the past that has not corrected your problem? (Choose as many as you like.)
Aspirin, Tylenol or Advil
Prescription Pain Medicine
What activities are being negatively affected? (Choose as many as you like.)
Sit to Stand
What aspects of your life are being negatively impacted? (Choose as many as you like.)
Marriage / Relationships
Ability to Exercise
On a scale of 0 - 10 how important is it for you to get this problem corrected?
Is there anything else you’d like to share with us regarding your goals?
What is your first and last name?
What is your phone number?
What is your email address?
Schedule An Appointment Today