• The Pain Signal Test™

    New Patient Form
  • What type of health insurance do you currently have?*
  • Please check any symptoms you have*
  • Gender*
  • Format: (000) 000-0000.
  • Date of Birth*
     - -

  • Important Information About HMO/EPO Coverage

    Most HMO and EPO insurance plans do not cover this blood test through an outside laboratory. However, a limited number of plans may provide coverage.If you have HMO or EPO insurance, please call us at 1-800-994-7246 to discuss your coverage options before proceeding. Medicare and PPO coverage is subject to eligibility, medical necessity and individual plan requirements.
  • Format: (000) 000-0000.
  • Do you have a Secondary Insurer?*
  • Format: (000) 000-0000.
  • How would you prefer The Pain Signal Test team to contact you about your testing inquiry?*

  • We will use your contact information to respond to your inquiry about testing. Selecting a contact method does not authorize unrelated marketing communications. Standard message and data rates may apply to text messages.

  • Should be Empty: