Are you a good candidate for a Spinal Cord Stimulation consultation?
Submit the form below, and our scheduling team will contact you as soon as possible to discuss your next steps. Or call our scheduling department at (480) 573-0130 and mention your interest in a Spinal Cord Stimulator consultation.
First Name
*
Last Name
*
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Do you experience chronic pain?
*
Yes
No
Have you experienced chronic pain for more than 3 months?
*
Yes
No
How would you rate your pain on a scale from 1-10? (1 = mild, 10 = severe)
*
Please Select
1 (Mild)
2
3
4
5
6
7
8
9
10 (Severe)
Which treatments have you tried for pain relief?
*
Chiropractic
Physical Therapy
Injections
Medications
Surgery
Other
How does chronic pain affect your daily activities?
*
Loss of Sleep
Loss of Physical Activity
Loss of Range of Motion
Other
Have you been diagnosed with any of the following conditions?
*
Failed Back Surgery Syndrome (FBSS)
Complex Regional Pain Syndrome (CRPS)
Lumbar Radiculopathy
Other
Submit
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