Tired of Band-Aid Treatments? Welcome to Care That Actually Lasts. Apply Below!
No gimmicks. No one-size-fits-all plans. Just personalized care designed to get you stronger, healthier, and pain-free for the long haul.
Step 1
Contact Information
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
Please select a month
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Month
Please select a day
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Day
Please select a year
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Year
Step 2
What Are You Struggling With?
1. Primary Issue (Most Pressing Complaint)
*
Headaches/Migraines
Neck Pain and Tightness
Back Pain and Tightness
Shoulder Pain and Tightness
Hip or Knee or Ankle/Foot Pain
Other
How long have you been dealing with this?
*
Please Select
Less than 1 month
1-3 months
3-6 months
6+ months
Many Years
What have you tried so far?
*
Other Chiropractors
Physical Therapy
Massage Therapy
Pain Meds & Rest
Surgery or Injections
Nothing yet just been putting it off
Why do you think the approaches you have tried already have not actually worked for you?
*
Step 3
Commitment & Readiness
What would your life look life WITHOUT this pain?
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What is stopping you from fixing this pain right now?
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Are you committed to following a customized plan to give yourself a great chance at getting lasting results?
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Yes, I am ready to fix this.
No, I am okay with my pain.
Are you willing and capable of investing into professional care and rehab program?
*
Yes, I understand that health is an investment and I am ready to move forward.
No, I do not value health as an investment and am not in a position to invest in my health right now.
At our first visit, we will determine if you are a good fit for one of our rehab programs. We will also determine if you are ready to take action and commit fully to the program that fits you. We do not discuss treatment/program pricing until after a full evaluation and consideration is completed to ensure you receive the best plan for your needs. Do you understand and agree to this policy?
*
Yes, I understand & agree
No, I do not wish to continue
Please note our clinic is NOT a clinic for you if you are just looking for a quick pop or getting your muscles stretched. That approach does not produce long lasting results, and we focus on providing patient's personalized rehab programs that focus on long term results not band aids.
*
Yes! I acknowledge this and am excited to finally consult a clinic that will help me get to the root cause of my pain and set me up for long term success and not just quick fixes.
No, I am okay with my pain and I do not care if I continue to deal with it for many years. I just want a quick pop even if it is not what I actually need.
What day(s) of the week and time blocks work for you to come in for your initial assessment (please give us several choices)?
*
I confirm by submitting this information and contact information on this website and form, that I am consenting to receive calls, SMS, voicemails, emails etc from Southern Spine & Rehab, PLLC and Dr. Kolten Pedigo, DC. We do not share your information with third party sources. Reply STOP to opt out.
*
Yes, I agree, consent, and acknowledge to all of this communication.
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