811 Coral Ridge Dr.Coral Springs, FL 33071

Pain Relief Centers of Homestead & Coral Springs

Call us now +1 786-947-9454

Fill Out This 30 Seconds Quiz To See If You Qualify For Your Treatment

Full Name

Email *

Phone Number *

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Where is your pain located? * *

Hips / pelvis

Sciatica / leg pain / arm pain

Neck

Other

How would you rate your pain or discomfort today? (On a scale of 1–5) *

1 – Mild

2 – Moderate

3 – Uncomfortable

4 – Severe

5 – Very severe

Please describe the issue or pain you're experiencing. *

How long have you been dealing with this issue? *

Less than 6 months

6–12 months

1–3 years

Over 3 years

Do you feel the pain spreading into your arms or legs? *

Yes

What symptoms are you currently experiencing? (Select all that apply) *

Pain when moving, walking, bending, or lifting

Swelling or stiffness

Numbness or tingling

Joint instability or weakness

Shooting pain (e.g. down the leg)

Clicking, popping, or joint locking

Difficulty standing, sitting, or climbing stairs

None of these

Have you had any spinal surgery before? *

Yes

Do you have any metal implants, hardware, or a pacemaker?

Yes

Have you been diagnosed with any of the following? (Select all that apply) *

Bulging / herniated disc

Degenerative disc disease

Spinal stenosis

Sciatica

None of the above

Are you actively looking for treatment or just exploring? *

Actively looking

Just exploring

Not sure

If you qualify, are you ready to start treatment? *

Yes, I’m ready to get started

Not yet, just researching

What days/times are you typically available for an appointment? *

What's your age? *

Address

Street Address

City

Postal code

Pain Relief Centers of Homestead & Coral Springs

Call Us Now +1 786-947-9454

811 Coral Ridge Dr. Coral Springs, FL 33071

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