first name:		last name:
address:
address2:
city:		state:	zip:
phone:	work
	home
email:
date of birth:

You must be a least 18 years of age to qualify for our free health check.

Which of the following are you suffering from? (check all that apply)
headaches neck pain neck and arm pain mid back pain sports injuries failed back surgery low back pain	low back and leg pain sinus and allergies numbness and tingling in arms/legs TMJ ringing in ears other

Have you been to Medi-Practic Pain Management before? yes no

Do you currently have health insurance coverage? yes no

Do you have medicare or medicaid? yes no
Federal law prohibits the use of this offer with Medicare or Medicaid.

How did you hear about Medi-Practic Pain Managment?

friend tv radio website other

please specify:

OFFICE HOURS - Monday, Wednesday, Friday 9:00am-8:00pm
                                                                   Tuesday 9:00am-1:00pm