Call Us Today:
(717) 322-0430
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Fill out the information below to get started
What is the level of pain you are experiencing? (10 being most severe)
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1
2
3
4
5
6
7
8
9
10
Where is the source of your pain? (check all that apply)
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Neck
Back
Knee
Shoulder
Arms
Legs
Other
What type of doctors have you seen for pain? (check all that apply)
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Chiropractor
Pain Management
Neurologist
Orthopedic Surgeon
General/Family Doctor
How did the pain begin? (check all that apply)
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Accident at Home
Vehicle Accident
Accident at Work/Work Related
"Just Began"
After Surgery
"Came on Gradually"
Sports Related
Have you had any surgeries related to your existing pain or any prior pain condition?
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Yes
No
The pain that you are experiencing is affecting what areas of your life? (check all that apply)
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maintaining a safe environment
communication
breathing
eating and drinking
elimination
washing and dressing
mobilization
working and playing
expressing sexuality
sleeping
daily parenting
finances
household chores
self worth/value
physical well-being
emotional health
How committed are you to fixing this pain TODAY?
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Very committed
Somewhat committed
Neutral
Not ready to commit yet
Which insurance (if any) do you have? (We are NOT a Medicaid provider)
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Cigna
Aetna
United Healthcare
Humana
BCBS
No Insurance
Other
What kind of work do you do?
*
What is your ZIP code?
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Here is our schedule. Please pick the day/time this week that generally works best for you. We will reach out to you soon to confirm if your appointment time is available (ie Monday at 3:30pm).
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Full Name
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Email
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Phone
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PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: "I will NOT miss my appointment once it is scheduled because I respect your time and I understand it is not fair to others who would have scheduled in my place if I don't show up."
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Yes
No
PLEASE ACKNOWLEDGE THE FOLLOWING: I understand that your office is located at 245 Bloomfield Drive, Suite 201 Lititz, PA 17543
*
Yes
No
Call Us Today:
(717) 322-0430
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