Patient First Name *

Patient Last Name *

Phone *

Email *

In what area of your body do you have pain? *

Please mark the following that apply to you to determine if you could benefit from Nerve Stimunlation Therapy: *

I have had pain for more than 2 months

Other forms of treatment have not been successful

I believe my pain is related to nerve pain

I want to stop taking pills for my pain

I want to avoid having surgery

I am interested in learning more about how Nerve Stimulation Therapy can eliminate my pain

If you were able to check one of the boxes above and are interested in coming to a FREE workshop about how Nerve Stimulation Therapy can help you, do you give us permission to contact you to determine if you are likely to benefit from this type of treatment? *

Yes