The Neuropathy Specialists

Laser Spine Institute: Your Care Center for Life

Complete This Brief Questionnaire

to Get Your Discount Voucher!

First Name *

Last Name *

Best Mobile Phone Number *

Best Email *

What pain symptoms are you experiencing right now? *

What pain symptoms are you experiencing in your feet OR hands?

Sharp Stabbing Pain
Numbness
Tingling
Pins and Needles
Burning
Loss of Balance
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List is empty.

Have you seen any other doctors for your Neuropathy symptoms? *

Have you seen any other doctors for your Neuropathy symptoms?

Yes
No
No elements found. Consider changing the search query.
List is empty.

On a scale of 1-10, 1 being hardly any pain and 10 being excruciating, how would you rate your pain? *

1

2

3

4

5

6

7

8

9

10

What medical insurance do you have? *

Traditional Medicare

AARP Medicare advantage

United Health Care Medicare advantage (UHC) (including Optum & Wahlgreens)

Tricare for life

Aetna Medicare Advantage

Other

How long have you been suffering with these issues? *

How long have you been suffering with these issues?

Less than 6 months
6 months to 12 months
Over a year
No elements found. Consider changing the search query.
List is empty.

PLEASE ACKNOWLEDGE THE FOLLOWING: I am committed to showing up to my appointment on time. If I CANNOT make my appointment time, I will give 24 hours notice to respect the doctor's time and the other patients who could have filled that appointment slot. *

Do you acknowledge our cancellation policy?

Yes
No
No elements found. Consider changing the search query.
List is empty.

What is your date of birth? *

How committed are you to getting your neuropathy pain under control? *

How committed are you to getting your neuropathy pain under control?

Very Committed
Somewhat Committed
Not Committed AT ALL (I accidentally clicked on this)
No elements found. Consider changing the search query.
List is empty.

0%

Complete This Brief Questionnaire to Get Your Discount Voucher!

First Name *

Last Name *

Best Mobile Phone Number *

Best Email *

What pain symptoms are you experiencing right now? *

What pain symptoms are you experiencing in your feet OR hands?

Sharp Stabbing Pain
Numbness
Tingling
Pins and Needles
Burning
Loss of Balance
No elements found. Consider changing the search query.
List is empty.

Have you seen any other doctors for your Neuropathy symptoms? *

Have you seen any other doctors for your Neuropathy symptoms?

Yes
No
No elements found. Consider changing the search query.
List is empty.

On a scale of 1-10, 1 being hardly any pain and 10 being excruciating, how would you rate your pain? *

1

2

3

4

5

6

7

8

9

10

What medical insurance do you have? *

Traditional Medicare

AARP Medicare advantage

United Health Care Medicare advantage (UHC) (including Optum & Wahlgreens)

Tricare for life

Aetna Medicare Advantage

Other

How long have you been suffering with these issues? *

How long have you been suffering with these issues?

Less than 6 months
6 months to 12 months
Over a year
No elements found. Consider changing the search query.
List is empty.

PLEASE ACKNOWLEDGE THE FOLLOWING: I am committed to showing up to my appointment on time. If I CANNOT make my appointment time, I will give 24 hours notice to respect the doctor's time and the other patients who could have filled that appointment slot. *

Do you acknowledge our cancellation policy?

Yes
No
No elements found. Consider changing the search query.
List is empty.

What is your date of birth? *

How committed are you to getting your neuropathy pain under control? *

How committed are you to getting your neuropathy pain under control?

Very Committed
Somewhat Committed
Not Committed AT ALL (I accidentally clicked on this)
No elements found. Consider changing the search query.
List is empty.

0%