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?

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

Have you seen any other doctors for your Neuropathy symptoms?

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?

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?

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?

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?

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

Have you seen any other doctors for your Neuropathy symptoms?

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?

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?

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?

0%