Midwest Institute For Non-Surgical Therapy - Illinois

1

Are Any Of The Following Symptoms Present?* This field is required.Select All That Apply & Click NEXT

Leg or Foot Pain

Numbness/Tingling

Toe Nail Thickening

Sores

2

How Long Have These Symptoms Been Present?* This field is required.Select One

Just recently

3-12 Months

1-5 Years

5+ Years

3

What Solutions Have Been Tried (If Any)?* This field is required.Select All That Apply & Click NEXT

Over the counter medication

Exercise

Neuropathy Medications

Arterial Procedures

Wound Care Treatment

Other/Nothing

4

Select Current Insurance Coverage* This field is required.Select One

Private insurance policy

Employer provided insurance

Medicare

Medicaid

No insurance

Other

5

Can We Get A Name?* This field is required.Enter First and Last Name

First Name

Last Name

6

Best Email Address?* This field is required.Enter Email Address

example@example.com

7

What Is Your Phone Number?Enter Your Phone Number

Area Code

Phone Number

8

Terms and Conditions* This field is required.

9

What Is Your Date Of Birth? * This field is required.

10

When is the best time to evaluate your circulation?* This field is required.Exam with a PAD Treatment Expert

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

11

Which location do you prefer?* This field is required.Select One

Swansea, IL

Evergreen Park, IL

Chicago, IL