📍 Optimize Health Chiropractic Center
15450 New Barn Road, Miami Lakes FL 33014
Breakthrough
Rapid Back Pain Relief Program
in Miami Lakes, FL
Check YOUR Eligibility
Who are you filling this out for?
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Myself
Husband
Wife
Daughter
Son
Other
What back pain symptoms are you experiencing?
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Sharp pain in the back
Trouble standing or sitting
Back muscle spasms
Pain when walking short distances
All of these above
Some of these above
On a scale from 1-5, 5 being “excruciating”, how bad is the pain in your back?
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1
2
3
4
5
How long have these symptoms been bothering you?
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Less than 1 year
1 - 3 years
4 - 6 years
6+ years
Have you been told you're a candidate for surgery?
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Yes
No
Have you been diagnosed with any of the following conditions?
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Herniated disc
Degenerative disc disease
Sciatica
Stenosis
None
Have you used opioids or steroid injections to mask the pain?
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Yes
No
I've had both
Financing options are available based on your credit. Which option best describes your credit history?
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Poor Credit (Below 650)
Average Credit (650-700)
Good Credit (700-750)
Great Credit (750+)
We are located in Miami Lakes, FL, is this commutable for you?
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Yes
No
Full Name
*
What's your best phone number?
*
What's your best email?
*
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